Provider Demographics
NPI:1114542834
Name:BOLL, ANGELA CHRISTINE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:CHRISTINE
Last Name:BOLL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 N WESTWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2303
Mailing Address - Country:US
Mailing Address - Phone:573-686-5550
Mailing Address - Fax:
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3027
Practice Address - Country:US
Practice Address - Phone:573-686-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127615367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered