Provider Demographics
NPI:1346668050
Name:BOSTIC, MIRANDA RESHAE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:RESHAE
Last Name:BOSTIC
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:RESHAE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:423-317-9344
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:2018 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37921-5718
Practice Address - Country:US
Practice Address - Phone:865-544-0406
Practice Address - Fax:865-544-0480
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26208363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner