Provider Demographics
NPI:1720332372
Name:BOLDUC, KATRINA JO (LM, CPM)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:JO
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 OLMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-3324
Mailing Address - Country:US
Mailing Address - Phone:805-748-2939
Mailing Address - Fax:805-265-7326
Practice Address - Street 1:61 5TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-5100
Practice Address - Country:US
Practice Address - Phone:805-748-2939
Practice Address - Fax:805-256-7326
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA673176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife