Healthcare Provider Details

I. General information

NPI: 1295061562
Provider Name (Legal Business Name): MANDY DIANNE BOLTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NEHEMIAH PL
LOS LUNAS NM
87031-7041
US

IV. Provider business mailing address

13 NEHEMIAH PL
LOS LUNAS NM
87031-7041
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-7814
  • Fax:
Mailing address:
  • Phone: 505-715-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: