Healthcare Provider Details

I. General information

NPI: 1114837580
Provider Name (Legal Business Name): KIMIKO CHANEE BOLDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 S ROGERS ST
POOLER GA
31322-3116
US

IV. Provider business mailing address

601 QUACCO RD UNIT 3804
SAVANNAH GA
31419-9912
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-6840
  • Fax:
Mailing address:
  • Phone: 912-390-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN305914
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: