Provider Demographics
NPI:1154576197
Name:BOSTIC, TAWANDA NITCHELLE (FNP-BC/PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:TAWANDA
Middle Name:NITCHELLE
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:FNP-BC/PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 STATESVILLE RD STE 6331
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7647
Mailing Address - Country:US
Mailing Address - Phone:704-641-7475
Mailing Address - Fax:704-992-9546
Practice Address - Street 1:6000 WESTERN PL
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4607
Practice Address - Country:US
Practice Address - Phone:704-641-7475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC196483163WM0705X, 363LF0000X, 363LP0808X
MTAPRN-LIC-127603363LF0000X
WAAP60975928363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC196483OtherNCBON- RN LICENSE
NC2008006354OtherANCC- FNP CERTIFICATION
NC2013020566OtherANCC
MTAPRN-LIC-127603OtherMONTANA APRN LICENSE