Healthcare Provider Details

I. General information

NPI: 1558284018
Provider Name (Legal Business Name): ANNA BOLTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CUNNINGHAM BLVD
BOONEVILLE MS
38829-1726
US

IV. Provider business mailing address

101 SEVENTH ST
BOONEVILLE MS
38829-2617
US

V. Phone/Fax

Practice location:
  • Phone: 662-720-7158
  • Fax:
Mailing address:
  • Phone: 706-977-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1122
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: