Healthcare Provider Details

I. General information

NPI: 1790129872
Provider Name (Legal Business Name): AMY KATHERINE BOLES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8219 LEESBURG PIKE STE 100
VIENNA VA
22182-2625
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-8025
US

V. Phone/Fax

Practice location:
  • Phone: 301-873-7508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9359225
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: