Provider Demographics
NPI:1992828057
Name:BOLDRA, JANINE M (PT)
Entity Type:Individual
Prefix:MRS
First Name:JANINE
Middle Name:M
Last Name:BOLDRA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 MIDWAY PL
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1165
Mailing Address - Country:US
Mailing Address - Phone:920-727-8155
Mailing Address - Fax:
Practice Address - Street 1:1550 MIDWAY PL
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1165
Practice Address - Country:US
Practice Address - Phone:920-727-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1690-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40132300Medicaid