Provider Demographics
NPI:1184725723
Name:BOLIN, CONNIE J (CRNA)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:BOLIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10310 STATE LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66206-2658
Mailing Address - Country:US
Mailing Address - Phone:913-647-4101
Mailing Address - Fax:913-647-4121
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:865-342-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO096957367500000X
MNCRNA 1929367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered