Provider Demographics
NPI:1447618640
Name:BOSTIC, SHALONDRIA
Entity Type:Individual
Prefix:
First Name:SHALONDRIA
Middle Name:
Last Name:BOSTIC
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 1:1575 52ND AVE N
Mailing Address - Street 2:3 YEARS
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2629
Mailing Address - Country:US
Mailing Address - Phone:727-550-7257
Mailing Address - Fax:
Practice Address - Street 1:1575 52ND AVE N
Practice Address - Street 2:3 YEARS
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-2629
Practice Address - Country:US
Practice Address - Phone:727-550-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906812311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home