Provider Demographics
NPI:1972171783
Name:BOSTIC, MARCHELLE
Entity Type:Individual
Prefix:
First Name:MARCHELLE
Middle Name:
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 1:2914 127TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-8053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 SE CABOT DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3715
Practice Address - Country:US
Practice Address - Phone:360-914-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61149299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist