Provider Demographics
NPI:1568972578
Name:BOSTON, ANNTIONEEK MARSHELLE
Entity Type:Individual
Prefix:
First Name:ANNTIONEEK
Middle Name:MARSHELLE
Last Name:BOSTON
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:PO BOX 733
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-0733
Mailing Address - Country:US
Mailing Address - Phone:678-744-3440
Mailing Address - Fax:
Practice Address - Street 1:1128 LORA SMITH RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1924
Practice Address - Country:US
Practice Address - Phone:678-744-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier