Provider Demographics
NPI:1518609486
Name:BOULDIN, ADAM NOAH (APRN)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:NOAH
Last Name:BOULDIN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 KITTY HAWK DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4722
Mailing Address - Country:US
Mailing Address - Phone:404-539-6248
Mailing Address - Fax:
Practice Address - Street 1:75 KITTY HAWK DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4722
Practice Address - Country:US
Practice Address - Phone:404-539-6248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA210847207P00000X, 2084P0800X
CAG143626363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry