Healthcare Provider Details

I. General information

NPI: 1154810612
Provider Name (Legal Business Name): PAIGE BOLES APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAIGE KIMBROUGH

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SE 14TH ST
BENTONVILLE AR
72712
US

IV. Provider business mailing address

3101 SE 14TH ST
BENTONVILLE AR
72712-4900
US

V. Phone/Fax

Practice location:
  • Phone: 479-986-6090
  • Fax:
Mailing address:
  • Phone: 479-986-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR098054
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA005666
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: