Provider Demographics
NPI:1336566157
Name:BOLAND, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:BOLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 LOG BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-8462
Mailing Address - Country:US
Mailing Address - Phone:803-245-5176
Mailing Address - Fax:
Practice Address - Street 1:370 LOG BRANCH RD
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003
Practice Address - Country:US
Practice Address - Phone:803-245-5176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37183251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare