Provider Demographics
NPI:1730374547
Name:BOLT, MELISSA JOY (CNP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JOY
Last Name:BOLT
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:JOY
Other - Last Name:BOLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:2504 WHITEGATE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-2326
Mailing Address - Country:US
Mailing Address - Phone:573-234-0834
Mailing Address - Fax:
Practice Address - Street 1:1605 E BROADWAY STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8031
Practice Address - Country:US
Practice Address - Phone:573-875-0555
Practice Address - Fax:573-875-0606
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019040447363L00000X
MNR1623130163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse