Basic Information
| Provider Information | |||||||||
| NPI: | 1518428283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDEN | ||||||||
| FirstName: | WILLIE MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 W PEELER AVE | ||||||||
| Address2: | |||||||||
| City: | SHAW | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387738710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627543301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 W PEELER AVE | ||||||||
| Address2: | |||||||||
| City: | SHAW | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387738710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627456638 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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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 | 363LF0000X | 903205 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.