Basic Information
| Provider Information | |||||||||
| NPI: | 1346668050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSTIC | ||||||||
| FirstName: | MIRANDA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 CLOVER CIR | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377574643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234949100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1096 ALPINE DR | ||||||||
| Address2: | |||||||||
| City: | SEVIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378767825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448142030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 26208 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.