Provider Demographics
NPI:1699371187
Name:BOLEN, JUDITH GAYLE
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:GAYLE
Last Name:BOLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2720
Mailing Address - Country:US
Mailing Address - Phone:304-469-2413
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:1799 MAIN ST E
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-2341
Practice Address - Country:US
Practice Address - Phone:304-465-0885
Practice Address - Fax:304-465-0886
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59057163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse