Provider Demographics
NPI:1437533320
Name:BOGUE, ANN M (FNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:BOGUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD # 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:429 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3508
Practice Address - Country:US
Practice Address - Phone:765-453-5600
Practice Address - Fax:765-455-0110
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013786363LF0000X
IN71005573A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201308690Medicaid
IN248870002Medicare PIN