Provider Demographics
NPI:1215475827
Name:BOSTON, ROYELLA
Entity type:Individual
Prefix:
First Name:ROYELLA
Middle Name:
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 1:1114 NEW YORK AVE
Mailing Address - Street 2:APT 1F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4957
Mailing Address - Country:US
Mailing Address - Phone:718-913-0549
Mailing Address - Fax:
Practice Address - Street 1:1114 NEW YORK AVE
Practice Address - Street 2:APT 1F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-4957
Practice Address - Country:US
Practice Address - Phone:718-913-0549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2717891171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
630204907OtherMETRO PLUS