Provider Demographics
NPI:1003470402
Name:BOLES, MITCHELL (APRN)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BOLES
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 HIGHWAY 34 E STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2404
Mailing Address - Country:US
Mailing Address - Phone:770-252-7557
Mailing Address - Fax:
Practice Address - Street 1:1665 HIGHWAY 34 E STE 100
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2404
Practice Address - Country:US
Practice Address - Phone:770-252-7557
Practice Address - Fax:770-252-7513
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233677363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty