Healthcare Provider Details

I. General information

NPI: 1386582757
Provider Name (Legal Business Name): ASHLEY BOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 CALUMET AVE
VALPARAISO IN
46383-2715
US

IV. Provider business mailing address

2505 CALUMET AVE
VALPARAISO IN
46383-2715
US

V. Phone/Fax

Practice location:
  • Phone: 219-548-3843
  • Fax: 219-548-3256
Mailing address:
  • Phone: 219-548-3843
  • Fax: 219-548-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: