Healthcare Provider Details

I. General information

NPI: 1689677213
Provider Name (Legal Business Name): KATHIE E BOLLENBACH M.M.S., P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 NC HIGHWAY 94 N
CRESWELL NC
27928-8300
US

IV. Provider business mailing address

PO BOX 669
AHOSKIE NC
27910-0669
US

V. Phone/Fax

Practice location:
  • Phone: 252-209-0237
  • Fax: 252-209-0197
Mailing address:
  • Phone: 252-209-0237
  • Fax: 252-209-0197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1233-023
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066417
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: