Provider Demographics
NPI:1972905164
Name:BOLDEN, TANYA (RN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BOLDEN
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 1:10812 CHERRY BLOSSOM CT
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-1043
Mailing Address - Country:US
Mailing Address - Phone:301-275-1519
Mailing Address - Fax:
Practice Address - Street 1:10812 CHERRY BLOSSOM CT
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-1043
Practice Address - Country:US
Practice Address - Phone:301-275-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001209513163W00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse