Provider Demographics
NPI:1306190178
Name:BOSTICK, ASHLEY LACEY (NP)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:LACEY
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:NP
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 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:
Practice Address - Street 1:8 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6783
Practice Address - Country:US
Practice Address - Phone:229-890-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181134363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner