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General NPI Number Information
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NPI Number | 1295437234
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Entity Type | Individual
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Provider Name | LASHASTA K BOLDEN
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Gender | Female
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Dates
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Enumeration Date | 03/21/2023
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Last Update Date | 03/21/2023
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Provider Practice Location Address
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Address Line | 118 HALLIBURTON ST
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City | RIPLEY
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State | TN
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Zip | 38063-2011
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Country | US
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Telephone | 731-635-5180
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Fax |
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Provider Business Mailing Address
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Address Line | 245 MURDOCK CV
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City | RIDGELY
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State | TN
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Zip | 38080-1509
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Country | US
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Telephone | 731-259-7738
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 3767
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License Number State | TN
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