Provider Demographics
NPI:1225109945
Name:BOLTON, SUSAN LYNN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:BOLTON
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 1:50 MACK AVE
Mailing Address - Street 2:#40
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5416
Practice Address - Country:US
Practice Address - Phone:810-987-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion