Basic Information
| Provider Information | |||||||||
| NPI: | 1265032445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | JENNI | ||||||||
| MiddleName: | LAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-CNP, AGNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913100 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 SUMMIT AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453733047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373355191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 0027579 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.