Provider Demographics
NPI:1558894303
Name:ROSE BOVINO, LEONIE LORRAINE (PHD, AGACNP-BC)
Entity Type:Individual
Prefix:DR
First Name:LEONIE
Middle Name:LORRAINE
Last Name:ROSE BOVINO
Suffix:
Gender:F
Credentials:PHD, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8008
Practice Address - Country:US
Practice Address - Phone:803-256-6511
Practice Address - Fax:803-376-5885
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27337363LA2100X
CT7263363LA2100X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health