Healthcare Provider Details

I. General information

NPI: 1376131565
Provider Name (Legal Business Name): JENNIFER ELIZABETH BOSLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 05/19/2022
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 S MAIN ST
UPLAND IN
46989-9257
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 765-770-0650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number28209545A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71010883A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: