Healthcare Provider Details

I. General information

NPI: 1184605743
Provider Name (Legal Business Name): THERESA M BOLEY CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CARPENTER ST 2ND FLOOR
SPRINGFIELD IL
62702-4901
US

IV. Provider business mailing address

PO BOX 19638
SPRINGFIELD IL
62794-9638
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-7422
  • Fax: 217-545-7053
Mailing address:
  • Phone: 217-545-7422
  • Fax: 217-545-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209000839
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: