Healthcare Provider Details

I. General information

NPI: 1144777095
Provider Name (Legal Business Name): STEPHANIE ANN BOSE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15519 CRENSHAW BLVD
GARDENA CA
90249-4525
US

IV. Provider business mailing address

15519 CRENSHAW BLVD
GARDENA CA
90249-4525
US

V. Phone/Fax

Practice location:
  • Phone: 310-679-9126
  • Fax:
Mailing address:
  • Phone: 310-679-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD1100X
TaxonomyPeritoneal Dialysis Registered Nurse
License Number550157
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number550157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: