Provider Demographics
NPI:1013650464
Name:BOLANO, SHEREE
Entity Type:Individual
Prefix:
First Name:SHEREE
Middle Name:
Last Name:BOLANO
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 1:16452 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-6602
Mailing Address - Country:US
Mailing Address - Phone:321-443-7844
Mailing Address - Fax:
Practice Address - Street 1:16452 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-6602
Practice Address - Country:US
Practice Address - Phone:321-443-7844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLEMT525827146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, IntermediateGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7863673267Medicaid