1730801739 NPI number — JODIE ANN BOLLING FNP

Table of content: JODIE ANN BOLLING FNP (NPI 1730801739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730801739 NPI number — JODIE ANN BOLLING FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLLING
Provider First Name:
JODIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS
Provider Other First Name:
JODIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730801739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 W OAKLAND AVE STE 310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-302-6565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 COMMONWEALTH DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273-4053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-679-6028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2022

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: 363L00000X , with the licence number:  0024185268 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0024185268 . This is a "LICENSE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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