Healthcare Provider Details

I. General information

NPI: 1881117521
Provider Name (Legal Business Name): KRISTY MICHILLE BOLT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTY MICHILLE GODFREY

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 MAYNARDVILLE HWY
MAYNARDVILLE TN
37807
US

IV. Provider business mailing address

1923 SULPHUR SPRINGS RD
MORRISTOWN TN
37813-5654
US

V. Phone/Fax

Practice location:
  • Phone: 865-992-3849
  • Fax: 865-992-5166
Mailing address:
  • Phone: 423-317-9344
  • Fax: 423-714-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN150366
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22497
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: