Provider Demographics
NPI:1932589322
Name:ANIFOWOSE, BOSE GRACE (DNP, FNP, PMHNP)
Entity type:Individual
Prefix:MS
First Name:BOSE
Middle Name:GRACE
Last Name:ANIFOWOSE
Suffix:
Gender:F
Credentials:DNP, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2381 E ALONSO DR
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85194-7460
Mailing Address - Country:US
Mailing Address - Phone:623-565-2668
Mailing Address - Fax:
Practice Address - Street 1:1075 W AVALON CANYON DR
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6706
Practice Address - Country:US
Practice Address - Phone:623-565-2668
Practice Address - Fax:520-635-5510
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7746363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health