Healthcare Provider Details

I. General information

NPI: 1639679822
Provider Name (Legal Business Name): RYAN MABE BOLT PMHNP-BC, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10620 TREENA ST STE 230
SAN DIEGO CA
92131-1140
US

IV. Provider business mailing address

10620 TREENA ST STE 230
SAN DIEGO CA
92131-1140
US

V. Phone/Fax

Practice location:
  • Phone: 858-609-9763
  • Fax: 504-290-1145
Mailing address:
  • Phone: 208-850-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95008584
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: