Provider Demographics
NPI:1194341412
Name:BOLTON, CAMILLE FRANNCINE (DPT)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:FRANNCINE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 DEVILLA CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4027
Mailing Address - Country:US
Mailing Address - Phone:404-539-0337
Mailing Address - Fax:
Practice Address - Street 1:500 FLOY FARR PARKWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:404-539-0337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTO14539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist