Provider Demographics
NPI:1205385218
Name:BOLDEN, SHIRLEY JEAN
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JEAN
Last Name:BOLDEN
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 1:3 BEEKMAN ST.
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209
Mailing Address - Country:US
Mailing Address - Phone:518-300-6558
Mailing Address - Fax:
Practice Address - Street 1:3 BEEKMAN ST.
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209
Practice Address - Country:US
Practice Address - Phone:518-300-6558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286922164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse