Provider Demographics
NPI:1881117521
Name:BOLT, KRISTY MICHILLE (APRN)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:MICHILLE
Last Name:BOLT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:MICHILLE
Other - Last Name:GODFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1923 SULPHUR SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-5654
Mailing Address - Country:US
Mailing Address - Phone:423-317-9344
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:4330 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807
Practice Address - Country:US
Practice Address - Phone:865-992-3849
Practice Address - Fax:865-992-5166
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN150366163W00000X
TN22497363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN22497OtherSTATE LICENSE