Basic Information
| Provider Information | |||||||||
| NPI: | 1326131830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLLSTETTER | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APRN, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 N MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895832794 | ||||||||
| FaxNumber: | 9895832811 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 N MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895832794 | ||||||||
| FaxNumber: | 9895832811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704075682 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 151144 | 01 | MI | GREAT LAKES HEALTH PLAN | OTHER | 5008754250 | 01 | MI | BCBSM | OTHER | 4704075682 | 01 | MI | LICENSE | OTHER | 4775840 | 05 | MI | MEDICAID |