Healthcare Provider Details

I. General information

NPI: 1558532598
Provider Name (Legal Business Name): VANESSA LYNN BOLYARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANESSA LYNN MITCHELL

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 8TH ST
SHALLOWATER TX
79363-5726
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-832-4566
  • Fax: 806-832-4143
Mailing address:
  • Phone: 806-785-2045
  • Fax: 806-785-0872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP116675
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: