Healthcare Provider Details

I. General information

NPI: 1801152921
Provider Name (Legal Business Name): SHERRY LYNN BOLES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CHATHAM GDNS APT A
ROCHESTER NY
14605-2035
US

IV. Provider business mailing address

104 CHATHAM GDNS APT A
ROCHESTER NY
14605-2035
US

V. Phone/Fax

Practice location:
  • Phone: 585-820-1317
  • Fax:
Mailing address:
  • Phone: 585-820-1317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number223601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: