1922432277 NPI number — MRS. GEORGIA FLETCHER BOLEY MS,RD,LD,CSO

Table of content: MRS. GEORGIA FLETCHER BOLEY MS,RD,LD,CSO (NPI 1922432277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922432277 NPI number — MRS. GEORGIA FLETCHER BOLEY MS,RD,LD,CSO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLEY
Provider First Name:
GEORGIA
Provider Middle Name:
FLETCHER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS,RD,LD,CSO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922432277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 BOX CROSS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERIDAN
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82801-9020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-752-8213
Provider Business Mailing Address Fax Number:
307-675-1866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 SMITH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHERIDAN
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82801-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-752-8213
Provider Business Practice Location Address Fax Number:
307-675-1866
Provider Enumeration Date:
08/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  87227 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 084 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 156924 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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