Healthcare Provider Details

I. General information

NPI: 1043249295
Provider Name (Legal Business Name): CHANDRA ANITA BOSTON C.F.P.M.H.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

PO BOX 157A
WHITFIELD MS
39193-0157
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4128
  • Fax: 601-815-1828
Mailing address:
  • Phone: 601-351-8000
  • Fax: 601-351-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR772275
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: