Provider Demographics
NPI:1417690272
Name:BOSCOE, STACEY LYNNE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNNE
Last Name:BOSCOE
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 1:3540 SOQUEL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1769
Mailing Address - Country:US
Mailing Address - Phone:831-600-8911
Mailing Address - Fax:800-808-2728
Practice Address - Street 1:3540 SOQUEL AVE STE D
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1769
Practice Address - Country:US
Practice Address - Phone:831-600-8911
Practice Address - Fax:800-808-2728
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOW0009884225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty