Provider Demographics
NPI:1821441833
Name:BOLEN, AMY MICHELLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:BOLEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4025 MONTEZUMA PL
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-1125
Mailing Address - Country:US
Mailing Address - Phone:937-901-8832
Mailing Address - Fax:
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019339363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily