Healthcare Provider Details

I. General information

NPI: 1790145191
Provider Name (Legal Business Name): ILLENA Y BOGGS APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6572 MIDLAND TRAIL RD
ASHLAND KY
41102-9286
US

IV. Provider business mailing address

6572 MIDLAND TRAIL RD
ASHLAND KY
41102-9286
US

V. Phone/Fax

Practice location:
  • Phone: 606-928-7755
  • Fax: 606-928-0052
Mailing address:
  • Phone: 606-928-7755
  • Fax: 606-928-0052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010111
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-50349
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: