Healthcare Provider Details

I. General information

NPI: 1487118964
Provider Name (Legal Business Name): EUGENIA BOLDYREVA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 BOATNER RD STE 114
EGLIN AFB FL
32542-1302
US

IV. Provider business mailing address

805 E RIVER PL
JACKSON MS
39202-3486
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8600
  • Fax:
Mailing address:
  • Phone: 601-500-7660
  • Fax: 769-243-7946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11022878
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903160
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: