Provider Demographics
NPI:1346227741
Name:BOLTON, MARY DARLENE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DARLENE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:FNP-BC
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 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:605 STADIUM DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-4156
Practice Address - Country:US
Practice Address - Phone:601-450-0310
Practice Address - Fax:601-450-0321
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR79429363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114669Medicaid
MS3565141OtherCIGNA
MS4593131OtherAETNA
MSR34683Medicare UPIN
MS500001256Medicare ID - Type UnspecifiedMS MEDICARE NUMBER