Provider Demographics
NPI:1114471232
Name:BOLDEN, DIANE MARGERY (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARGERY
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 THOMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4139
Mailing Address - Country:US
Mailing Address - Phone:315-489-5463
Mailing Address - Fax:
Practice Address - Street 1:411 THOMPSON BLVD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4139
Practice Address - Country:US
Practice Address - Phone:315-489-5463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302276-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse