Healthcare Provider Details

I. General information

NPI: 1063062644
Provider Name (Legal Business Name): KATIE ELIZABETH BOLTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 TULLYCROSS CT
TIMONIUM MD
21093-1940
US

IV. Provider business mailing address

771 CHESTNUT RD
EAST LANSING MI
48824-3434
US

V. Phone/Fax

Practice location:
  • Phone: 443-615-5242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002114
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: