Provider Demographics
NPI:1801801568
Name:BOLSER, MARY CAY (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CAY
Last Name:BOLSER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CAY
Other - Last Name:DECLUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-3311
Mailing Address - Fax:
Practice Address - Street 1:311 W FAIRCHILD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3876
Practice Address - Country:US
Practice Address - Phone:217-431-7898
Practice Address - Fax:217-554-1750
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000358363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCE9335OtherRR GROUP
ILP00393307OtherRR MEDICARE NUMBER
ILK26728Medicare ID - Type Unspecified
ILCE9335OtherRR GROUP
ILK38612Medicare PIN