Healthcare Provider Details

I. General information

NPI: 1487045308
Provider Name (Legal Business Name): JAN BOLTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2015
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 OMNI PARK DR
MOBILE AL
36609-5195
US

IV. Provider business mailing address

6150 OMNI PARK DR
MOBILE AL
36609-5195
US

V. Phone/Fax

Practice location:
  • Phone: 251-639-7959
  • Fax:
Mailing address:
  • Phone: 251-639-7959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number1039998
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: