Provider Demographics
NPI:1427328608
Name:BOLAND, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BOLAND
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 1:1218 KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:DOWNS
Mailing Address - State:KS
Mailing Address - Zip Code:67437-1404
Mailing Address - Country:US
Mailing Address - Phone:785-454-3378
Mailing Address - Fax:
Practice Address - Street 1:1218 KANSAS ST
Practice Address - Street 2:
Practice Address - City:DOWNS
Practice Address - State:KS
Practice Address - Zip Code:67437-1404
Practice Address - Country:US
Practice Address - Phone:785-454-3378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02289225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant