Provider Demographics
NPI:1891264545
Name:BOSSOLONO-WILLIAMS, TINA MONIQUE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MONIQUE
Last Name:BOSSOLONO-WILLIAMS
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 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6011
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:
Practice Address - Street 1:512 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4871
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID40406363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care