Provider Demographics
NPI:1457017204
Name:BOLDEN, JAMIE (NP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 FM 723 RD STE 550
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-9238
Mailing Address - Country:US
Mailing Address - Phone:937-830-1948
Mailing Address - Fax:
Practice Address - Street 1:9115 FM 723 RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-9234
Practice Address - Country:US
Practice Address - Phone:937-830-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC005537363L00000X
DC500009897363LF0000X
TX1058717363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner