1366452971 NPI number — FANNIE GRACE BOLDEN RN APNC

Table of content: FANNIE GRACE BOLDEN RN APNC (NPI 1366452971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366452971 NPI number — FANNIE GRACE BOLDEN RN APNC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLDEN
Provider First Name:
FANNIE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN APNC
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:
1366452971
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:
115 WRIGHT AVE
Provider Second Line Business Mailing Address:
APT D34
Provider Business Mailing Address City Name:
STRATFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-783-2175
Provider Business Mailing Address Fax Number:
856-963-2185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-365-3519
Provider Business Practice Location Address Fax Number:
856-963-2185
Provider Enumeration Date:
08/08/2006

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: 363LX0001X , with the licence number:  26NN01681200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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