Healthcare Provider Details

I. General information

NPI: 1922170943
Provider Name (Legal Business Name): JUDITH A BOLTON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 NORTH EAST AVENUE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

2950 W DELHI RD
ANN ARBOR MI
48103-9010
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4963
  • Fax:
Mailing address:
  • Phone: 734-769-4809
  • Fax: 734-769-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704075734
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: