Provider Demographics
NPI:1316910367
Name:YOUNG-BOLDEN, THELMA LYNN (RN, MSN, CS)
Entity type:Individual
Prefix:
First Name:THELMA
Middle Name:LYNN
Last Name:YOUNG-BOLDEN
Suffix:
Gender:F
Credentials:RN, MSN, CS
Other - Prefix:
Other - First Name:THELMA
Other - Middle Name:LYNN
Other - Last Name:YOUNG - FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, CS
Mailing Address - Street 1:4323 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5551
Mailing Address - Country:US
Mailing Address - Phone:812-334-3342
Mailing Address - Fax:
Practice Address - Street 1:4323 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5551
Practice Address - Country:US
Practice Address - Phone:812-334-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000117A364SP0809X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P77890Medicare UPIN
IN198320Medicare ID - Type Unspecified