Provider Demographics
NPI:1255973251
Name:BOSTIC, OCTAVIA
Entity type:Individual
Prefix:
First Name:OCTAVIA
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 1:7670 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1173
Mailing Address - Country:US
Mailing Address - Phone:863-777-3846
Mailing Address - Fax:
Practice Address - Street 1:7670 CREEKSIDE LANE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296
Practice Address - Country:US
Practice Address - Phone:863-777-3846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide