Provider Demographics
NPI:1497402515
Name:BOULWARE, BAILEY DANIELLE
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:DANIELLE
Last Name:BOULWARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 STANTON L YOUNG BLVD STE 1140
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5036
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:
Practice Address - Street 1:920 STANTON L YOUNG BLVD STE 1140
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:405-271-8695
Is Sole Proprietor?:No
Enumeration Date:2022-03-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK208889367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered