MEDICARE: MRS. MARY LEE BOSCHULTE CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	143576	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NP 01416	OTHER	OH	NURSE PRACTITIONER
2	R.N. 143576	OTHER	OH	REGISTERED NURSE LICENSE

General Provider Information

NPI Number	:	1114035953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY LEE BOSCHULTE CRNP

Provider Business Mailing Address
First Line	:	1811 HALLECK PL
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3222
Country	:	US
Telephone Number	:	614-732-2481
Fax Number	:	614-236-0632

Provider Business Practice Location Address
First Line	:	1811 HALLECK PL
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3222
Country	:	US
Telephone Number	:	614-732-2481
Fax Number	:	614-236-0632

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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