Provider Demographics
NPI:1780057539
Name:BOLDEN, REBEL ANN (CST, CSFA)
Entity type:Individual
Prefix:MS
First Name:REBEL
Middle Name:ANN
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 BROKEN ARROW PASS
Mailing Address - Street 2:
Mailing Address - City:QUINLAN
Mailing Address - State:TX
Mailing Address - Zip Code:75474-6402
Mailing Address - Country:US
Mailing Address - Phone:469-891-7304
Mailing Address - Fax:
Practice Address - Street 1:4215 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX163077246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant