Provider Demographics
NPI:1871880856
Name:BOSTIC, MINDY L (PNP)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:L
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1343
Mailing Address - Country:US
Mailing Address - Phone:304-872-1663
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:10003 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:CAMDEN ON GAULEY
Practice Address - State:WV
Practice Address - Zip Code:26208-7713
Practice Address - Country:US
Practice Address - Phone:304-226-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57113363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics