Healthcare Provider Details

I. General information

NPI: 1376153544
Provider Name (Legal Business Name): MELANIE SHEVONNE BOLEN DNP, APRN-CNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W HOLLAND AVE
WHITE HALL AR
71602-9241
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 870-619-4451
  • Fax:
Mailing address:
  • Phone: 870-347-2534
  • Fax: 870-347-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125425
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: