Healthcare Provider Details

I. General information

NPI: 1578199865
Provider Name (Legal Business Name): MADISON WHITLOCK BOSWELL CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 TODAYS WOMAN AVE
WINSTON SALEM NC
27105-5069
US

IV. Provider business mailing address

404 WESTWOOD AVE STE 103
HIGH POINT NC
27262-4316
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-1818
  • Fax: 336-722-1826
Mailing address:
  • Phone: 336-409-6504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5012980
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: