Provider Demographics
NPI:1750011748
Name:BOLLS, PHYLIA IRENE
Entity Type:Individual
Prefix:
First Name:PHYLIA
Middle Name:IRENE
Last Name:BOLLS
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 1:3610 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:IL
Mailing Address - Zip Code:60428-3811
Mailing Address - Country:US
Mailing Address - Phone:708-600-2005
Mailing Address - Fax:
Practice Address - Street 1:16918 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2768
Practice Address - Country:US
Practice Address - Phone:708-600-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041464045163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergencyGroup - Single Specialty