Healthcare Provider Details

I. General information

NPI: 1790368231
Provider Name (Legal Business Name): BRENDA KAY BOSWELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 UNION UNIVERSITY DR STE A
JACKSON TN
38305-3856
US

IV. Provider business mailing address

31 ARBUCKLE LN
JACKSON TN
38305-5736
US

V. Phone/Fax

Practice location:
  • Phone: 731-664-0103
  • Fax:
Mailing address:
  • Phone: 731-664-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number37032
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: