Provider Demographics
NPI:1679632939
Name:BOSLEY, JEANETTA LEE (MD)
Entity type:Individual
Prefix:
First Name:JEANETTA
Middle Name:LEE
Last Name:BOSLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:270-422-5000
Mailing Address - Fax:270-422-5052
Practice Address - Street 1:534 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1222
Practice Address - Country:US
Practice Address - Phone:270-422-5000
Practice Address - Fax:270-422-5052
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY25268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64252687Medicaid
KY080105100Medicare PIN
KY64252687Medicaid
KYE01325Medicare UPIN