Provider Demographics
NPI:1841563749
Name:BOHLE, ANNE KATHERINE (PA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:KATHERINE
Last Name:BOHLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PAVILION AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-1522
Mailing Address - Country:US
Mailing Address - Phone:401-461-9110
Mailing Address - Fax:401-461-9194
Practice Address - Street 1:66 PAVILION AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-1522
Practice Address - Country:US
Practice Address - Phone:401-461-9110
Practice Address - Fax:401-461-9194
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004229225400000X
RIPA00854363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner