Provider Demographics
NPI:1346668050
Name:BOSTIC, MIRANDA (NP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:BOSTIC
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 1:307 CLOVER CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-4643
Mailing Address - Country:US
Mailing Address - Phone:423-494-9100
Mailing Address - Fax:
Practice Address - Street 1:1096 ALPINE DR
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37876-7825
Practice Address - Country:US
Practice Address - Phone:844-814-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26208363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner