Provider Demographics
NPI:1275179574
Name:BOLTON, STEPHANIE ELIZABETH (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24927
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-4927
Mailing Address - Country:US
Mailing Address - Phone:423-643-2576
Mailing Address - Fax:423-648-4570
Practice Address - Street 1:7345 COURAGE WAY STE 1
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1555
Practice Address - Country:US
Practice Address - Phone:423-602-9797
Practice Address - Fax:423-602-9796
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30996363LP0808X
TN229228163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse