Provider Demographics
NPI:1376664532
Name:BOATNER, DENISE E (MS, CCC-A)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:E
Last Name:BOATNER
Suffix:
Gender:F
Credentials:MS, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 PEGRAM DR
Mailing Address - Street 2:P.O. BOX 2180
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6322
Mailing Address - Country:US
Mailing Address - Phone:662-844-3583
Mailing Address - Fax:662-840-8354
Practice Address - Street 1:618 PEGRAM DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6322
Practice Address - Country:US
Practice Address - Phone:662-844-3583
Practice Address - Fax:662-840-8354
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA2838237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04701341Medicaid