1932487022 NPI number — MS. SHELLY ANN BOSTON APRN-CNP

Table of content: MS. SHELLY ANN BOSTON APRN-CNP (NPI 1932487022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932487022 NPI number — MS. SHELLY ANN BOSTON APRN-CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSTON
Provider First Name:
SHELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932487022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 SOUTH 7TH STREET
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
VINITA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74301-3720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-256-1501
Provider Business Mailing Address Fax Number:
918-323-0460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 S 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
VINITA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74301-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-256-1501
Provider Business Practice Location Address Fax Number:
918-323-0460
Provider Enumeration Date:
07/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  78693 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200509690H . This is a "GROUP MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200390480A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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