Healthcare Provider Details

I. General information

NPI: 1700704079
Provider Name (Legal Business Name): AMANDA RAE BOLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA RAE GRANT B.A.

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

3 WESTCHESTER PARK DR APT 219
WEST HARRISON NY
10604-3445
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5731
  • Fax:
Mailing address:
  • Phone: 313-268-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number358820
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: