Provider Demographics
NPI:1659378669
Name:BOLTON, PAMELA JEWEL (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEWEL
Last Name:BOLTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 CLIFTON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45220-3027
Mailing Address - Country:US
Mailing Address - Phone:513-861-5555
Mailing Address - Fax:513-861-6980
Practice Address - Street 1:3219 CLIFTON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-3027
Practice Address - Country:US
Practice Address - Phone:513-861-5555
Practice Address - Fax:513-861-6980
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-08040363LA2100X
KY39848363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78904109Medicaid
OH2535877Medicaid
KY0369019Medicare ID - Type UnspecifiedMEDICARE NUMBER
KY0562619Medicare ID - Type UnspecifiedMEDICARE NUMBER
OHBONP16983Medicare ID - Type UnspecifiedMEDICARE NUMBER
KY78904109Medicaid
KY0369212Medicare ID - Type UnspecifiedMEDICARE NUMBER
OHBONP16981Medicare ID - Type UnspecifiedMEDICARE NUMBER
OHBONP16982Medicare ID - Type UnspecifiedMEDICARE NUMBER