Provider Demographics
NPI:1093839946
Name:BOLDS, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOLDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 RANCH POINT WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8051
Mailing Address - Country:US
Mailing Address - Phone:925-755-7874
Mailing Address - Fax:925-755-7874
Practice Address - Street 1:1000 WARD ST
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-1360
Practice Address - Country:US
Practice Address - Phone:925-335-4707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN169231164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse