Healthcare Provider Details

I. General information

NPI: 1013837509
Provider Name (Legal Business Name): KEVANNA BOLTON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 JAMES ST
BRIDGEPORT WV
26330-1336
US

IV. Provider business mailing address

444 JAMES ST
BRIDGEPORT WV
26330-1336
US

V. Phone/Fax

Practice location:
  • Phone: 304-629-6825
  • Fax:
Mailing address:
  • Phone: 304-629-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: