MEDICARE: MRS. TELISHA BOGGAN CNA

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	376K00000X	Nurse's Aide	CNA200986	FL

General Provider Information

NPI Number	:	1710632468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TELISHA BOGGAN CNA

Provider Business Mailing Address
First Line	:	1992 LEWIS TURNER BLVD STE 1067112
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1255
Country	:	US
Telephone Number	:	850-296-2952
Fax Number	:

Provider Business Practice Location Address
First Line	:	1992 LEWIS TURNER BLVD STE 1067112
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1255
Country	:	US
Telephone Number	:	850-296-2952
Fax Number	:

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

Provider Enumeration Date	:	02/21/2022
Last Update Date	:	02/21/2022

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