Healthcare Provider Details

I. General information

NPI: 1558252528
Provider Name (Legal Business Name): MARISSA BOLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 BELLEVUE CIR
JACKSONVILLE AR
72076-3841
US

IV. Provider business mailing address

214 BELLEVUE CIR
JACKSONVILLE AR
72076-3841
US

V. Phone/Fax

Practice location:
  • Phone: 501-352-9764
  • Fax:
Mailing address:
  • Phone: 501-352-9764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: