Provider Demographics
NPI:1881853109
Name:BOLES, SHERRY RENEE (MAE)
Entity Type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:RENEE
Last Name:BOLES
Suffix:
Gender:F
Credentials:MAE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 BEWLEYTOWN RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN RUN
Mailing Address - State:KY
Mailing Address - Zip Code:42133-8573
Mailing Address - Country:US
Mailing Address - Phone:270-774-1647
Mailing Address - Fax:270-434-3433
Practice Address - Street 1:1853 BEWLEYTOWN RD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN RUN
Practice Address - State:KY
Practice Address - Zip Code:42133-8573
Practice Address - Country:US
Practice Address - Phone:270-774-1647
Practice Address - Fax:270-434-3433
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist