Provider Demographics
NPI:1679191902
Name:BOLE, JAMIE LYNN (CNP)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LYNN
Last Name:BOLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 KIRTS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4135
Mailing Address - Country:US
Mailing Address - Phone:248-434-6169
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:3515 MASSILLON RD STE 250
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-7854
Practice Address - Country:US
Practice Address - Phone:330-896-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00032347363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily