Healthcare Provider Details

I. General information

NPI: 1912736802
Provider Name (Legal Business Name): JAMES TRAVIS BOLT ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 BRIDGEPORT WAY SW STE 2
LAKEWOOD WA
98499-2449
US

IV. Provider business mailing address

302 CHAMPION ST
STEILACOOM WA
98388-1108
US

V. Phone/Fax

Practice location:
  • Phone: 253-393-9099
  • Fax:
Mailing address:
  • Phone: 915-730-4282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number61590376
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: