MEDICARE: SHANNIAH BOSEMAN

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	376K00000X	Nurse's Aide	10045249	PA

General Provider Information

NPI Number	:	1962143941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNIAH BOSEMAN

Provider Business Mailing Address
First Line	:	11 AQUAMARINE CT
Second Line	:
City	:	DOVER
State	:	DE
Zip	:	19904-3706
Country	:	US
Telephone Number	:	267-255-2465
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 N NATRONA ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-2413
Country	:	US
Telephone Number	:	267-417-5080
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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