Healthcare Provider Details

I. General information

NPI: 1790674943
Provider Name (Legal Business Name): PRISCILLA BOATENG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2575
US

IV. Provider business mailing address

257 CROSSROADS STORE DR
JACKSONVILLE NC
28546-0129
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberR194705
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: