Provider Demographics
NPI:1184605743
Name:BOLEY, THERESA M (CFNP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:BOLEY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19638
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9638
Mailing Address - Country:US
Mailing Address - Phone:217-545-7422
Mailing Address - Fax:217-545-7053
Practice Address - Street 1:315 W CARPENTER ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4901
Practice Address - Country:US
Practice Address - Phone:217-545-7422
Practice Address - Fax:217-545-7053
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL449580260001Medicaid
ILL72178Medicare PIN
S85973Medicare UPIN
IL522000Medicare PIN