Provider Demographics
NPI:1043249295
Name:BOSTON, CHANDRA ANITA (CFPMHNP)
Entity Type:Individual
Prefix:MS
First Name:CHANDRA
Middle Name:ANITA
Last Name:BOSTON
Suffix:
Gender:F
Credentials:CFPMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157A
Mailing Address - Street 2:
Mailing Address - City:WHITFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39193-0157
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8301
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-4128
Practice Address - Fax:601-815-1828
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR772275363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09528347Medicaid
MS411763YJ5DMedicare PIN