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NPI Code Detail

MEDICARE: TINA MONIQUE BOSSOLONO-WILLIAMS

MEDICARE: TINA MONIQUE BOSSOLONO-WILLIAMS
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
1363LP2300XPrimary Care Nurse Practitioner40406ID

General Provider Information

NPI Number : 1891264545
Entity Type Code : Individual
Provider Name (Legal Business Name) : TINA MONIQUE BOSSOLONO-WILLIAMS
Provider Business Mailing Address
First Line : PO BOX 190930
Second Line :
City : BOISE
State : ID
Zip : 83719-0930
Country : US
Telephone Number : 208-236-5170
Fax Number : 208-367-5180
Provider Business Practice Location Address
First Line : 1510 12TH AVE RD STE 200
Second Line :
City : NAMPA
State : ID
Zip : 83686-6946
Country : US
Telephone Number : 208-302-6800
Fax Number : 208-302-6855
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/23/2018
Last Update Date : 09/30/2024

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Directions to “ TINA MONIQUE BOSSOLONO-WILLIAMS ” Practice Location

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