Provider Demographics
NPI:1104636067
Name:BOLTON, ADELYN GRACE
Entity type:Individual
Prefix:
First Name:ADELYN
Middle Name:GRACE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 CHIMNEY VIEW RD
Mailing Address - Street 2:
Mailing Address - City:SAUTEE NACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571-1870
Mailing Address - Country:US
Mailing Address - Phone:706-969-1671
Mailing Address - Fax:
Practice Address - Street 1:205 PEACH ORCHARD RD
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:GA
Practice Address - Zip Code:30511-1803
Practice Address - Country:US
Practice Address - Phone:706-778-8377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant