Basic Information
| Provider Information | |||||||||
| NPI: | 1497008916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSU | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARY | ||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 TOWNSEND AVE APT 2E | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104526023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6463017858 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2054 TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104751560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186712100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2012 | ||||||||
| LastUpdateDate: | 08/09/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 305415 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.