Basic Information
| Provider Information | |||||||||
| NPI: | 1922339837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOELLA ENTERPRISES,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4277 STEF LN NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301527700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704191799 | ||||||||
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| Practice Location | |||||||||
| Address1: | 811 KENNESAW AVE NW | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704222451 | ||||||||
| FaxNumber: | 7704992235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2010 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | CAIN | ||||||||
| AuthorizedOfficialFirstName: | TRINA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7704191799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | APRN,BC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN054027NP | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.