Provider Demographics
NPI:1740872068
Name:BOOSE, NICOLE RENE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:BOOSE
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 1:820 CHARLEVOIX DR STE 204
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-7100
Mailing Address - Country:US
Mailing Address - Phone:517-667-2664
Mailing Address - Fax:
Practice Address - Street 1:820 CHARLEVOIX DR STE 204
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-7100
Practice Address - Country:US
Practice Address - Phone:517-667-2664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide