Healthcare Provider Details

I. General information

NPI: 1578263661
Provider Name (Legal Business Name): ANNALEE KATHARYN BOLDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 2ND AVE
COLUMBUS GA
31904-7408
US

IV. Provider business mailing address

5033 HALE DR
COLUMBUS GA
31904-4839
US

V. Phone/Fax

Practice location:
  • Phone: 706-507-9209
  • Fax:
Mailing address:
  • Phone: 229-977-2659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.2639
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11437
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: