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General NPI Number Information
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NPI Number | 1417159161
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Entity Type | Individual
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Provider Name | NICOLE IZETTA BOSTIC MD
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Gender | Female
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 03/18/2015
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Provider Practice Location Address
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Address Line | 9041 MAGNOLIA AVE STE. 305
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City | RIVERSIDE
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State | CA
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Zip | 92503-3900
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Country | US
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Telephone | 951-343-3481
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Fax |
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Provider Business Mailing Address
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Address Line | 1412 ROADRUNNER DR
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City | CORONA
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State | CA
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Zip | 92881-0711
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Country | US
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Telephone | 314-322-2056
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Fax |
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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 | 2007018726
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | C55464
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License Number State | CA
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