Provider Demographics
NPI:1578908786
Name:BOLTER, BRIANNA NICOLE
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:NICOLE
Last Name:BOLTER
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 1:10924 CEDAR HEDGE TRL
Mailing Address - Street 2:
Mailing Address - City:INTERLOCHEN
Mailing Address - State:MI
Mailing Address - Zip Code:49643-9708
Mailing Address - Country:US
Mailing Address - Phone:231-715-8908
Mailing Address - Fax:
Practice Address - Street 1:990 GARFIELD WOODS DR STE B
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-5160
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program