Provider Demographics
NPI:1700604386
Name:BOLIVAR, KETSIA (PHARMD)
Entity type:Individual
Prefix:
First Name:KETSIA
Middle Name:
Last Name:BOLIVAR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 WOODLAND CIR
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-3104
Mailing Address - Country:US
Mailing Address - Phone:305-979-4281
Mailing Address - Fax:
Practice Address - Street 1:822 NE 125TH ST STE 109
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5729
Practice Address - Country:US
Practice Address - Phone:954-861-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator