Provider Demographics
NPI:1184754210
Name:BOLTON, KASEY L (PNP)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:L
Last Name:BOLTON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ENOTA DR NE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3473
Mailing Address - Country:US
Mailing Address - Phone:770-534-5255
Mailing Address - Fax:770-287-3871
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE
Practice Address - Street 2:STE 200
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3871
Practice Address - Country:US
Practice Address - Phone:770-297-7277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN134351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA377733892AMedicaid