Provider Demographics
NPI:1639679822
Name:BOLT, RYAN MABE (PMHNP-BC, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MABE
Last Name:BOLT
Suffix:
Gender:M
Credentials:PMHNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 TREENA ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1140
Mailing Address - Country:US
Mailing Address - Phone:208-850-6422
Mailing Address - Fax:
Practice Address - Street 1:10620 TREENA ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1140
Practice Address - Country:US
Practice Address - Phone:858-609-9763
Practice Address - Fax:504-290-1145
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008584363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily