Healthcare Provider Details

I. General information

NPI: 1104175736
Provider Name (Legal Business Name): CHRISTY DAWN BOSWELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTI DAWN BOSWELL

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S. BLISS AVENUE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1387W 4TH ST
TAHLEQUAH OK
74464-9766
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 918-453-5554
  • Fax: 918-431-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77908
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: