Provider Demographics
NPI:1861844037
Name:BOGGS, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:BOGGS
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0236
Mailing Address - Country:US
Mailing Address - Phone:260-463-2133
Mailing Address - Fax:260-463-3775
Practice Address - Street 1:2500 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1158
Practice Address - Country:US
Practice Address - Phone:260-463-2133
Practice Address - Fax:260-463-3775
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006343A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily