Provider Demographics
NPI:1629068705
Name:BOSTIC, LORETTA ANN (CRNA, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:ANN
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:CRNA, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 LICK BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-6761
Mailing Address - Country:US
Mailing Address - Phone:304-208-0707
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:661 LICK BRANCH RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-6761
Practice Address - Country:US
Practice Address - Phone:304-208-0707
Practice Address - Fax:855-851-4405
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV33849367500000X
WV106941363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered