Provider Demographics
NPI:1457782179
Name:BOLEN, KIMBERLY (FNP)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:BOLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:BOLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:COOL RIDGE
Mailing Address - State:WV
Mailing Address - Zip Code:25825-0663
Mailing Address - Country:US
Mailing Address - Phone:304-222-0479
Mailing Address - Fax:
Practice Address - Street 1:856 RITTER DR
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-9513
Practice Address - Country:US
Practice Address - Phone:304-255-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN64281-FNP-BC363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV120140218001994Medicare PIN