Provider Demographics
NPI:1063043008
Name:BOSHART, BONNIE ANN (FNP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:ANN
Last Name:BOSHART
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7366 WIGGINS MILL RD
Mailing Address - Street 2:
Mailing Address - City:LUCAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27851-9478
Mailing Address - Country:US
Mailing Address - Phone:252-205-5198
Mailing Address - Fax:
Practice Address - Street 1:200 GLENDALE DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2772
Practice Address - Country:US
Practice Address - Phone:252-399-0737
Practice Address - Fax:252-399-0747
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012764207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine