Provider Demographics
NPI:1356982128
Name:BOLTZ, SHAUNA (NP)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:BOLTZ
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 1:3440 BELL ST UNIT 122
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-4100
Mailing Address - Country:US
Mailing Address - Phone:806-379-9225
Mailing Address - Fax:806-331-4497
Practice Address - Street 1:3440 BELL ST UNIT 122
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-4100
Practice Address - Country:US
Practice Address - Phone:806-379-9225
Practice Address - Fax:806-331-4497
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily