Healthcare Provider Details

I. General information

NPI: 1629345608
Provider Name (Legal Business Name): MRS. KYOUNG S BOLTUC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2011
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629TH MEDICAL COMPANY UNIT # 15342
APO AP
96258-5342
US

IV. Provider business mailing address

629TH MEDICAL COMPANY UNIT # 15342
APO AP CA
96258-5342
US

V. Phone/Fax

Practice location:
  • Phone: 315-732-7396
  • Fax:
Mailing address:
  • Phone: 315-732-7396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number403434
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: