Provider Demographics
NPI:1235743162
Name:BOLDEN, SHYMEKA
Entity Type:Individual
Prefix:
First Name:SHYMEKA
Middle Name:
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 1:405 DEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 DEWITT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203
Practice Address - Country:US
Practice Address - Phone:769-232-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health