Provider Demographics
NPI:1275235590
Name:BOMAN, KENZI LEE
Entity Type:Individual
Prefix:
First Name:KENZI
Middle Name:LEE
Last Name:BOMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 ROSELING XING
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3858
Mailing Address - Country:US
Mailing Address - Phone:801-663-6195
Mailing Address - Fax:
Practice Address - Street 1:14502 N DALE MABRY HWY STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2040
Practice Address - Country:US
Practice Address - Phone:801-663-6195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025232208D00000X
FLAPRN11025232363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice