Provider Demographics
NPI:1790205896
Name:BOLES, NICOLE KRISTIN (LPN)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:KRISTIN
Last Name:BOLES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:KRISTIN LAWRENCE
Other - Last Name:BOLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:341 STATE ROUTE 1628
Mailing Address - Street 2:
Mailing Address - City:BARDWELL
Mailing Address - State:KY
Mailing Address - Zip Code:42023-8530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 BLY ST.
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:IL
Practice Address - Zip Code:62953
Practice Address - Country:US
Practice Address - Phone:618-309-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.120833164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043.120833OtherLICENSED PRACTICAL NURSE