Provider Demographics
NPI:1265289003
Name:BOLLER, CARMELA MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:CARMELA
Middle Name:MARIE
Last Name:BOLLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAINE STREET
Mailing Address - Street 2:MSO LIBRARY
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044
Mailing Address - Country:US
Mailing Address - Phone:785-505-2988
Mailing Address - Fax:
Practice Address - Street 1:325 MAINE ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1360
Practice Address - Country:US
Practice Address - Phone:785-505-3350
Practice Address - Fax:785-505-2874
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-83128-031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30005159780001Medicaid