Provider Demographics
NPI:1316455959
Name:BOLDEN, AUDREY ANNE (NP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANNE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 N OAK TRFY STE LL1
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2262
Mailing Address - Country:US
Mailing Address - Phone:816-691-1655
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1366
Practice Address - Country:US
Practice Address - Phone:636-625-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002061363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner