Provider Demographics
NPI:1851509442
Name:BOLLER, PATRICIA A (RN)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:BOLLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1701
Mailing Address - Country:US
Mailing Address - Phone:631-754-1189
Mailing Address - Fax:
Practice Address - Street 1:511 PULASKI RD
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-1701
Practice Address - Country:US
Practice Address - Phone:631-754-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY378-172-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01782287Medicaid