Healthcare Provider Details

I. General information

NPI: 1851569628
Provider Name (Legal Business Name): DAWNINE MARIE BOLDON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E TYRANENA PARK RD
LAKE MILLS WI
53551-9678
US

IV. Provider business mailing address

200 E TYRANENA PARK RD
LAKE MILLS WI
53551-9678
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-8170
  • Fax: 920-648-8225
Mailing address:
  • Phone: 920-648-8170
  • Fax: 920-648-8225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number966-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: