Healthcare Provider Details

I. General information

NPI: 1932613809
Provider Name (Legal Business Name): BRENN ALINE BOLDING PA-C, MS, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 EDWARDS MILL RD STE 200
RALEIGH NC
27612-5243
US

IV. Provider business mailing address

3001 EDWARDS MILL RD
RALEIGH NC
27612-5243
US

V. Phone/Fax

Practice location:
  • Phone: 919-863-6856
  • Fax:
Mailing address:
  • Phone: 919-781-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14785
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: