Provider Demographics
NPI:1578263661
Name:BOLDT, ANNALEE KATHARYN
Entity Type:Individual
Prefix:
First Name:ANNALEE
Middle Name:KATHARYN
Last Name:BOLDT
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 1:5033 HALE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4839
Mailing Address - Country:US
Mailing Address - Phone:229-977-2659
Mailing Address - Fax:
Practice Address - Street 1:3702 2ND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7408
Practice Address - Country:US
Practice Address - Phone:706-507-9209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant