Provider Demographics
NPI:1619299351
Name:BOLTON, TAMMIE LATISHA
Entity Type:Individual
Prefix:MR
First Name:TAMMIE
Middle Name:LATISHA
Last Name:BOLTON
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 1:6642 68TH ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-9765
Mailing Address - Country:US
Mailing Address - Phone:941-896-0611
Mailing Address - Fax:941-567-0452
Practice Address - Street 1:6642 68TH ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-9765
Practice Address - Country:US
Practice Address - Phone:941-896-0611
Practice Address - Fax:941-567-0452
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL231506251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based