1538244777 NPI number — JILL MARIE BOSE RN

Table of content: JILL MARIE BOSE RN (NPI 1538244777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538244777 NPI number — JILL MARIE BOSE RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSE
Provider First Name:
JILL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1538244777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 MAGELLAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGS PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11754-3801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-269-9826
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COPIAGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11726-3111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-691-7080
Provider Business Practice Location Address Fax Number:
631-691-3387
Provider Enumeration Date:
10/26/2006

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: 163W00000X , with the licence number:  3679801 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3679801 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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