Provider Demographics
NPI:1336328574
Name:BOLMAN, IVA JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:JEAN
Last Name:BOLMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 18
Mailing Address - Street 2:RR 8 HC5
Mailing Address - City:RELIANCE
Mailing Address - State:SD
Mailing Address - Zip Code:57369
Mailing Address - Country:US
Mailing Address - Phone:605-473-0852
Mailing Address - Fax:
Practice Address - Street 1:601 GALL ST.
Practice Address - Street 2:
Practice Address - City:LOWER BRULE
Practice Address - State:SD
Practice Address - Zip Code:57548
Practice Address - Country:US
Practice Address - Phone:605-473-0852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD003859164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse