Provider Demographics
NPI:1689677213
Name:BOLLENBACH, KATHIE E (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:E
Last Name:BOLLENBACH
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-0669
Mailing Address - Country:US
Mailing Address - Phone:252-209-0237
Mailing Address - Fax:252-209-0197
Practice Address - Street 1:9500 NC HIGHWAY 94 N
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:NC
Practice Address - Zip Code:27928-8300
Practice Address - Country:US
Practice Address - Phone:252-209-0237
Practice Address - Fax:252-209-0197
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1233-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851477913OtherCMH NPI
WI390848401050OtherANTHEM
WI11014110Medicaid
WIMH0537069OtherDEA #
WI390848401050OtherANTHEM
WIMH0537069OtherDEA #