Healthcare Provider Details

I. General information

NPI: 1215069075
Provider Name (Legal Business Name): CYNTHIA BOSTICK APRN, BC, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 CHAPARRAL ST
LAS CRUCES NM
88001-5701
US

IV. Provider business mailing address

1924 SAN FERNANDO DR
LAS CRUCES NM
88011-4163
US

V. Phone/Fax

Practice location:
  • Phone: 505-522-6404
  • Fax:
Mailing address:
  • Phone: 949-375-2858
  • Fax: 505-522-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR34639
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: