Provider Demographics
NPI:1518903152
Name:BOLIVAR-CANO, MARIE D (DNP, ACNP-BC, CEN)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:D
Last Name:BOLIVAR-CANO
Suffix:
Gender:F
Credentials:DNP, ACNP-BC, CEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-823-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172352363L00000X
IL209.008509363L00000X
AL1-071148363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL112913Medicaid
AL515-99504OtherBLUE CROSS BLUE SHIELD
AL1518903152OtherTRICARE SOUTH
AL891010870Medicaid
AL891010870Medicaid
AL051532696BOLMedicare ID - Type Unspecified
AL112913Medicaid