Provider Demographics
NPI:1053774539
Name:BOSTARDI, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOSTARDI
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 1:820 PINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6524
Mailing Address - Country:US
Mailing Address - Phone:330-393-0598
Mailing Address - Fax:
Practice Address - Street 1:820 PINE AVE SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6524
Practice Address - Country:US
Practice Address - Phone:330-393-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN123146-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse