Provider Demographics
NPI:1366452971
Name:BOLDEN, FANNIE GRACE (RN APNC)
Entity Type:Individual
Prefix:
First Name:FANNIE
Middle Name:GRACE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:RN APNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WRIGHT AVE
Mailing Address - Street 2:APT D34
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084
Mailing Address - Country:US
Mailing Address - Phone:856-783-2175
Mailing Address - Fax:856-963-2185
Practice Address - Street 1:317 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08013
Practice Address - Country:US
Practice Address - Phone:856-365-3519
Practice Address - Fax:856-963-2185
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN01681200363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology