Provider Demographics
NPI:1790219061
Name:BOLES, KEELYN
Entity Type:Individual
Prefix:MS
First Name:KEELYN
Middle Name:
Last Name:BOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KEELYN
Other - Middle Name:
Other - Last Name:BOLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2030 HAMILTON PLACE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-6040
Mailing Address - Country:US
Mailing Address - Phone:423-498-3788
Mailing Address - Fax:
Practice Address - Street 1:2030 HAMILTON PLACE BLVD STE 220
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6040
Practice Address - Country:US
Practice Address - Phone:423-498-3788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24190363LF0000X
TN198603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily