Provider Demographics
NPI:1912892928
Name:BOLTON, RAYNA DELAROSE (LE)
Entity type:Individual
Prefix:
First Name:RAYNA
Middle Name:DELAROSE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5057 SE REEDWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6154
Mailing Address - Country:US
Mailing Address - Phone:256-929-8845
Mailing Address - Fax:
Practice Address - Street 1:2031 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2812
Practice Address - Country:US
Practice Address - Phone:503-894-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORBAP-E-10256325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist