Provider Demographics
NPI:1285912162
Name:BOLUS, BRANDY A (LPN)
Entity type:Individual
Prefix:MS
First Name:BRANDY
Middle Name:A
Last Name:BOLUS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 PECK AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1522
Mailing Address - Country:US
Mailing Address - Phone:631-383-8281
Mailing Address - Fax:
Practice Address - Street 1:1853 PECK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1522
Practice Address - Country:US
Practice Address - Phone:631-383-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10306140164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse