Provider Demographics
NPI:1376182261
Name:BOLT, NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BOLT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 CENTRAL AVE APT 140
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5188
Mailing Address - Country:US
Mailing Address - Phone:870-405-4424
Mailing Address - Fax:
Practice Address - Street 1:2525 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:770-862-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27242367500000X
NC298943367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered