MEDICARE: DR. TAWANDA NITCHELLE BOSTIC FNP-BC/PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WM0705X	Medical-Surgical Registered Nurse	196483	NC
2	363LF0000X	Family Nurse Practitioner	APRN-LIC-127603	MT
3	363LF0000X	Family Nurse Practitioner	196483	NC
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	196483	NC
5	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP60975928	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	196483	OTHER	NC	NCBON- RN LICENSE
2	2008006354	OTHER	NC	ANCC- FNP CERTIFICATION
3	2013020566	OTHER	NC	ANCC
4	APRN-LIC-127603	OTHER	MT	MONTANA APRN LICENSE

General Provider Information

NPI Number	:	1154576197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAWANDA NITCHELLE BOSTIC FNP-BC/PMHNP-BC

Provider Business Mailing Address
First Line	:	9805 STATESVILLE RD STE 6331
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-7647
Country	:	US
Telephone Number	:	704-641-7475
Fax Number	:	704-992-9546

Provider Business Practice Location Address
First Line	:	6000 WESTERN PL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4607
Country	:	US
Telephone Number	:	704-641-7475
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2008
Last Update Date	:	09/03/2020

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Directions to “ DR. TAWANDA NITCHELLE BOSTIC FNP-BC/PMHNP-BC” Practice Location

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