Basic Information
| Provider Information | |||||||||
| NPI: | 1669941142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDUC | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 N MARR RD STE B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472012610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 N MARR RD STE B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472012610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123750272 | ||||||||
| FaxNumber: | 8123751093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 28160216A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 364S00000X | 71008787A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
No ID Information.