Healthcare Provider Details

I. General information

NPI: 1871355578
Provider Name (Legal Business Name): MARY BOLELA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 HOLLY HILL DR
JACKSON MS
39212-5867
US

IV. Provider business mailing address

242 HOLLY HILL DR
JACKSON MS
39212-5867
US

V. Phone/Fax

Practice location:
  • Phone: 601-573-9458
  • Fax:
Mailing address:
  • Phone: 601-573-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number875417
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: