MEDICARE: LORETTA ANN BOSTIC CRNA, 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	367500000X	Certified Registered Nurse Anesthetist	33849	WV
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	106941	WV

General Provider Information

NPI Number	:	1629068705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORETTA ANN BOSTIC CRNA, PMHNP-BC

Provider Business Mailing Address
First Line	:	661 LICK BRANCH RD
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25312-6761
Country	:	US
Telephone Number	:	304-208-0707
Fax Number	:	855-851-4405

Provider Business Practice Location Address
First Line	:	661 LICK BRANCH RD
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25312-6761
Country	:	US
Telephone Number	:	304-208-0707
Fax Number	:	855-851-4405

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

Provider Enumeration Date	:	10/28/2005
Last Update Date	:	07/23/2024

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