Provider Demographics
NPI:1689187908
Name:BOLYARD, MISTY DIANNE
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DIANNE
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:DIANNE
Other - Last Name:LANHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 ELEVENTH STREET
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-9150
Mailing Address - Fax:304-636-9157
Practice Address - Street 1:40 ELEVENTH STREET
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-9150
Practice Address - Fax:304-636-9157
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV84241163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse