Provider Demographics
NPI:1104518372
Name:BOLDRA, KRISTEN LEANN
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LEANN
Last Name:BOLDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEANN
Other - Last Name:GARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 W WASHBOURNE ST
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-4205
Mailing Address - Country:US
Mailing Address - Phone:918-308-5513
Mailing Address - Fax:918-253-6645
Practice Address - Street 1:1015 W WASHBOURNE ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-4205
Practice Address - Country:US
Practice Address - Phone:918-308-5513
Practice Address - Fax:918-253-6645
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist