Healthcare Provider Details

I. General information

NPI: 1841563749
Provider Name (Legal Business Name): ANNE KATHERINE BOHLE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 PAVILION AVE
PROVIDENCE RI
02905-1522
US

IV. Provider business mailing address

66 PAVILION AVE
PROVIDENCE RI
02905-1522
US

V. Phone/Fax

Practice location:
  • Phone: 401-461-9110
  • Fax: 401-461-9194
Mailing address:
  • Phone: 401-461-9110
  • Fax: 401-461-9194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number085.004229
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00854
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: