Provider Demographics
NPI:1114151461
Name:BOLAND, JUDITH RENE (RN, MSN, ACNS-BC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:RENE
Last Name:BOLAND
Suffix:
Gender:F
Credentials:RN, MSN, ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2305 SOUTH 65 HIGHWAY
Mailing Address - Street 2:P.O. BOX 250
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-886-7431
Mailing Address - Fax:660-886-9001
Practice Address - Street 1:2305 SOUTH 65 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-886-7431
Practice Address - Fax:660-886-9001
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO145142364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
X43000006Medicare PIN