Healthcare Provider Details

I. General information

NPI: 1043031891
Provider Name (Legal Business Name): GLORIA BOLAND BSN, RN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S MILWAUKEE AVE
LIBERTYVILLE IL
60048-3204
US

IV. Provider business mailing address

3 BRIGANTINE LN
THIRD LAKE IL
60030-2601
US

V. Phone/Fax

Practice location:
  • Phone: 847-990-5579
  • Fax:
Mailing address:
  • Phone: 630-291-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041.244215
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: