Provider Demographics
NPI:1215414065
Name:BOLDEN, DELLA ANASTASIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:DELLA
Middle Name:ANASTASIA
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19949 FENTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1069
Mailing Address - Country:US
Mailing Address - Phone:248-918-5188
Mailing Address - Fax:
Practice Address - Street 1:19949 FENTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1069
Practice Address - Country:US
Practice Address - Phone:248-918-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704324210163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse