Provider Demographics
NPI:1598229718
Name:BOSWELL, CLYDE RUSSELL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:RUSSELL
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:CLYDE
Other - Middle Name:RUSSELL
Other - Last Name:BOSWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CLYDE BOSWELL
Mailing Address - Street 1:1102 14TH ST N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3662
Mailing Address - Country:US
Mailing Address - Phone:615-830-6176
Mailing Address - Fax:
Practice Address - Street 1:8705 PERIMETER PARK BLVD STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6353
Practice Address - Country:US
Practice Address - Phone:904-248-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11012607363LF0000X
TN25373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily