Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | R133237 | MD |
NPI | 1053396986 |
---|---|
Provider Name | Kristina I Boushehri |
First Address | Fulton, MD 20759-2565 |
Second Address | Fulton, MD 20759-2565 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2005 |
Last Update Date | 06/07/2011 |