Provider Demographics
NPI:1821457854
Name:BOSMAN, MARY THERESIA (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESIA
Last Name:BOSMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 W NIELSON RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48657-9604
Mailing Address - Country:US
Mailing Address - Phone:989-687-7196
Mailing Address - Fax:
Practice Address - Street 1:1180 W NIELSON RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:MI
Practice Address - Zip Code:48657-9604
Practice Address - Country:US
Practice Address - Phone:989-687-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily