Provider Demographics
NPI:1831301068
Name:BOSTIC, TAMMY SUE
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:SUE
Last Name:BOSTIC
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 1:3417 STATE ROUTE 93
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638
Mailing Address - Country:US
Mailing Address - Phone:740-533-1037
Mailing Address - Fax:
Practice Address - Street 1:6975 COUNTY ROAD 4
Practice Address - Street 2:
Practice Address - City:PEDRO
Practice Address - State:OH
Practice Address - Zip Code:45659
Practice Address - Country:US
Practice Address - Phone:740-643-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2466737Medicaid