Provider Demographics
NPI:1003646449
Name:BOLLING, MICHELLE RENEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:BOLLING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3773
Mailing Address - Country:US
Mailing Address - Phone:423-782-6160
Mailing Address - Fax:
Practice Address - Street 1:4260 FORT HENRY DR STE 18
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2248
Practice Address - Country:US
Practice Address - Phone:423-406-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care