Provider Demographics
NPI:1851154918
Name:BOSTIC, GWENDOLYN MICHELLE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:MICHELLE
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 1:6854 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-5313
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:314-868-2561
Practice Address - Street 1:6854 PARKER RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-5313
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:314-868-2561
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200421978163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care