Healthcare Provider Details

I. General information

NPI: 1417159161
Provider Name (Legal Business Name): NICOLE IZETTA BOSTIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9041 MAGNOLIA AVE STE. 305
RIVERSIDE CA
92503-3900
US

IV. Provider business mailing address

1412 ROADRUNNER DR
CORONA CA
92881-0711
US

V. Phone/Fax

Practice location:
  • Phone: 951-343-3481
  • Fax:
Mailing address:
  • Phone: 314-322-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007018726
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC55464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: