Provider Demographics
NPI:1265032445
Name:BOLTON, JENNI LAYNE (APRN-CNP, AGNP-C)
Entity Type:Individual
Prefix:
First Name:JENNI
Middle Name:LAYNE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:APRN-CNP, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3100
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:550 SUMMIT AVE STE 101
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-3047
Practice Address - Country:US
Practice Address - Phone:937-335-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0027579363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health