Provider Demographics
NPI:1508541004
Name:BOLDEN, LATAIRRICKA07/11/198
Entity Type:Individual
Prefix:
First Name:LATAIRRICKA07/11/198
Middle Name:
Last Name:BOLDEN
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 1:103 S AVALON ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4165
Mailing Address - Country:US
Mailing Address - Phone:870-732-1878
Mailing Address - Fax:870-702-7111
Practice Address - Street 1:103 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4165
Practice Address - Country:US
Practice Address - Phone:870-732-1878
Practice Address - Fax:870-702-7111
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator