Provider Demographics
NPI:1437360518
Name:BOLTON, THERESA (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3969 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3466
Mailing Address - Country:US
Mailing Address - Phone:313-640-4074
Mailing Address - Fax:313-876-0070
Practice Address - Street 1:1151 TAYLOR STREET, 212-A
Practice Address - Street 2:DETROIT HEALTH DEPT - COMMUNICABLE DISEASE DIVISION
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-1732
Practice Address - Country:US
Practice Address - Phone:313-876-4138
Practice Address - Fax:313-876-0070
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704184140163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health