Provider Demographics
NPI:1801467998
Name:BOLLA, REBECCA A (DO)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:BOLLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 240TH PL SW
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-9456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 240TH PL SW
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-9456
Practice Address - Country:US
Practice Address - Phone:206-501-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program