Provider Demographics
NPI:1730656075
Name:BOSSIE, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BOSSIE
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 1:310 E SHORE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-2432
Mailing Address - Country:US
Mailing Address - Phone:516-514-5522
Mailing Address - Fax:
Practice Address - Street 1:310 E SHORE RD STE 203
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2432
Practice Address - Country:US
Practice Address - Phone:516-514-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308772363LA2200X, 363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology