Provider Demographics
NPI:1790167419
Name:BOLDON, KATELYN (NP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:BOLDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 SWENSON ST
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-3804
Mailing Address - Country:US
Mailing Address - Phone:937-243-7857
Mailing Address - Fax:
Practice Address - Street 1:4432 SWENSON ST
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-3804
Practice Address - Country:US
Practice Address - Phone:937-243-7857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17927363LP0808X
OH400921163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse