Provider Demographics
NPI:1699330761
Name:BOLIVARD, RODIEL (RN)
Entity type:Individual
Prefix:MR
First Name:RODIEL
Middle Name:
Last Name:BOLIVARD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22107 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2132
Mailing Address - Country:US
Mailing Address - Phone:347-400-6221
Mailing Address - Fax:
Practice Address - Street 1:7403 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1839
Practice Address - Country:US
Practice Address - Phone:718-264-4805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-04
Last Update Date:2024-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY768103163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse