Provider Demographics
NPI:1144777095
Name:BOSE, STEPHANIE ANN (RN)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:BOSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15519 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4525
Mailing Address - Country:US
Mailing Address - Phone:310-679-9126
Mailing Address - Fax:
Practice Address - Street 1:15519 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4525
Practice Address - Country:US
Practice Address - Phone:310-679-9126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550157163WD1100X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WD1100XNursing Service ProvidersRegistered NurseDialysis, Peritoneal