Provider Demographics
NPI:1760552665
Name:BOLES, SHANNON KRISTINE (ACNP)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KRISTINE
Last Name:BOLES
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-5298
Mailing Address - Fax:888-824-2176
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DIV SURG ACCS, STE 340
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-5298
Practice Address - Fax:888-824-2176
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165054363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420007468Medicaid