Provider Demographics
NPI:1225777683
Name:BOLDUC, DANA LYNN
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:LYNN
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:LYNN
Other - Last Name:BOLDUC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 N NOREN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-8773
Mailing Address - Country:US
Mailing Address - Phone:906-250-5380
Mailing Address - Fax:
Practice Address - Street 1:415 N NOREN LAKE DR
Practice Address - Street 2:
Practice Address - City:GWINN
Practice Address - State:MI
Practice Address - Zip Code:49841-8773
Practice Address - Country:US
Practice Address - Phone:906-250-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47033818163W00000X
MI4704338918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse