Provider Demographics
NPI:1972828762
Name:BOSTON, TYWANDA RENEE
Entity Type:Individual
Prefix:
First Name:TYWANDA
Middle Name:RENEE
Last Name:BOSTON
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 1:3179 N 47ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216
Mailing Address - Country:US
Mailing Address - Phone:414-975-8608
Mailing Address - Fax:
Practice Address - Street 1:4916 W FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4338
Practice Address - Country:US
Practice Address - Phone:414-975-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide