Healthcare Provider Details

I. General information

NPI: 1194967026
Provider Name (Legal Business Name): KRISTINA BOULEY OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 OLIVER ST # SR
FAYETTEVILLE NC
28304-4450
US

IV. Provider business mailing address

4530 NORTHERN SKY DR
BISMARCK ND
58503-8534
US

V. Phone/Fax

Practice location:
  • Phone: 910-483-8331
  • Fax: 910-483-8335
Mailing address:
  • Phone: 701-751-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number6868
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: