Healthcare Provider Details

I. General information

NPI: 1063194603
Provider Name (Legal Business Name): ALISA BOLTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SCHOENERSVILLE RD
BETHLEHEM PA
18017-7300
US

IV. Provider business mailing address

1330 POWELL ST
NORRISTOWN PA
19401-3353
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-6164
  • Fax:
Mailing address:
  • Phone: 484-622-7280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN696039
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: