Provider Demographics
NPI:1225381684
Name:BOLES, SHAHEEDAH
Entity type:Individual
Prefix:
First Name:SHAHEEDAH
Middle Name:
Last Name:BOLES
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 1:785 KING GEORGE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9501
Mailing Address - Country:US
Mailing Address - Phone:912-318-8764
Mailing Address - Fax:
Practice Address - Street 1:785 KING GEORGE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-9501
Practice Address - Country:US
Practice Address - Phone:912-318-8764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN151817363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health