Healthcare Provider Details

I. General information

NPI: 1952161549
Provider Name (Legal Business Name): TARETHA LATREAS BOOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3804 TYLER BLUFF LN
RALEIGH NC
27616-8328
US

IV. Provider business mailing address

1631 MIDTOWN PL STE 104-138
RALEIGH NC
27609-1300
US

V. Phone/Fax

Practice location:
  • Phone: 919-825-7291
  • Fax:
Mailing address:
  • Phone: 919-825-7291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number307592
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: