1063519643 NPI number — CANDACE ANN BOLTON-FLYNN M.S.

Table of content: CANDACE ANN BOLTON-FLYNN M.S. (NPI 1063519643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063519643 NPI number — CANDACE ANN BOLTON-FLYNN M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLTON-FLYNN
Provider First Name:
CANDACE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.
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:
1063519643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4590 MARSHA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTOSI
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53820-9683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-763-2973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6058 S CHESTNUT ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PLATTEVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53818-8947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-342-4863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2006

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: 101YM0800X , with the licence number:  1739-125 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39196200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com