Provider Demographics
NPI:1780328393
Name:BOLIN, AMANDA (FNP-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOLIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 HOOD RD
Mailing Address - Street 2:
Mailing Address - City:VALE
Mailing Address - State:OR
Mailing Address - Zip Code:97918-5370
Mailing Address - Country:US
Mailing Address - Phone:541-212-2744
Mailing Address - Fax:
Practice Address - Street 1:1118 NW 16TH ST STE D
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2272
Practice Address - Country:US
Practice Address - Phone:208-452-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID72434363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily