Healthcare Provider Details

I. General information

NPI: 1073135778
Provider Name (Legal Business Name): PATRICE REANN BOSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4390 CASA GRANDE CIR
CYPRESS CA
90630-6104
US

IV. Provider business mailing address

4390 CASA GRANDE CIR
CYPRESS CA
90630-6104
US

V. Phone/Fax

Practice location:
  • Phone: 562-682-6618
  • Fax:
Mailing address:
  • Phone: 562-682-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95094586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: