Healthcare Provider Details

I. General information

NPI: 1881983583
Provider Name (Legal Business Name): SHENEVIA NICHOLE BOSTICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 N LECANTO HWY
LECANTO FL
34461-9195
US

IV. Provider business mailing address

8477 S SUNCOAST BLVD
HOMOSASSA FL
34446-5028
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-9143
  • Fax:
Mailing address:
  • Phone: 352-382-1141
  • Fax: 352-382-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 22576
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: