Provider Demographics
NPI:1184952277
Name:BOLDEN, PHALAN LARESE (NP)
Entity type:Individual
Prefix:
First Name:PHALAN
Middle Name:LARESE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:NP
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 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-373-0212
Mailing Address - Fax:704-373-1216
Practice Address - Street 1:507 N LINDSAY ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4303
Practice Address - Country:US
Practice Address - Phone:336-883-0029
Practice Address - Fax:336-883-0867
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC255762363LF0000X
MA259383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006359Medicaid
SCNP2129Medicaid
NC1184952277Medicaid
NC1184952277Medicaid