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General NPI Number Information
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NPI Number | 1265513212
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Entity Type | Individual
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Provider Name | ETTA WILCIA BOSS COLE MD
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Gender | Female
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 303 HARRIS INDUSTRIAL BLVD STE 3
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City | VIDALIA
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State | GA
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Zip | 30474-8854
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Country | US
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Telephone | 912-537-9355
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Fax | 123-738-0969
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Provider Business Mailing Address
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Address Line | 303 HARRIS INDUSTRIAL BLVD STE 3
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City | VIDALIA
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State | GA
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Zip | 30474-8854
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Country | US
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Telephone | 912-537-9355
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Fax | 912-373-8096
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 055541
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License Number State | GA
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