Provider Demographics
NPI:1649895442
Name:BOLLING, GAYNELLE
Entity type:Individual
Prefix:
First Name:GAYNELLE
Middle Name:
Last Name:BOLLING
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 1:102 MANDARIN DR
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27863-0020
Mailing Address - Country:US
Mailing Address - Phone:919-214-1911
Mailing Address - Fax:
Practice Address - Street 1:102 MANDARIN DR
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27863-0020
Practice Address - Country:US
Practice Address - Phone:919-214-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
85-1342554OtherINTERNAL REVENUE SERVICE