Healthcare Provider Details

I. General information

NPI: 1184754210
Provider Name (Legal Business Name): KASEY L BOLTON PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 JESSE JEWELL PKWY SE STE 200
GAINESVILLE GA
30501-3871
US

IV. Provider business mailing address

200 S ENOTA DR NE SUITE 150
GAINESVILLE GA
30501-3473
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-7277
  • Fax:
Mailing address:
  • Phone: 770-534-5255
  • Fax: 770-287-3871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN134351
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: