Provider Demographics
NPI:1477017283
Name:BOCANEGRA, NORMA JEAN
Entity Type:Individual
Prefix:MRS
First Name:NORMA
Middle Name:JEAN
Last Name:BOCANEGRA
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 1:103 W PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-1850
Mailing Address - Country:US
Mailing Address - Phone:423-280-4374
Mailing Address - Fax:
Practice Address - Street 1:103 W PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-1850
Practice Address - Country:US
Practice Address - Phone:423-280-4374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054382257172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty