Healthcare Provider Details

I. General information

NPI: 1912378050
Provider Name (Legal Business Name): MARYANNE BOLT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 E 81ST ST STE 2000
TULSA OK
74137-4224
US

IV. Provider business mailing address

2488 E 81ST ST STE 2000
TULSA OK
74137-4224
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-4700
  • Fax: 918-592-2020
Mailing address:
  • Phone: 918-592-9020
  • Fax: 918-481-4709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number98345
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: