Provider Demographics
NPI:1689445850
Name:BOSTOCK, TASHIA SHADAI
Entity Type:Individual
Prefix:
First Name:TASHIA
Middle Name:SHADAI
Last Name:BOSTOCK
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 1:1839 SHAFTESBURY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3911
Mailing Address - Country:US
Mailing Address - Phone:937-516-0858
Mailing Address - Fax:
Practice Address - Street 1:3109 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-4122
Practice Address - Country:US
Practice Address - Phone:937-278-0761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402099220818376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide