Provider Demographics
NPI:1891594164
Name:BOLDEN, LYNETTE
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:BOLDEN
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 1:20010 MANDERSON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-1264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13919 S PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2916
Practice Address - Country:US
Practice Address - Phone:402-896-9988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 253Z00000X
NE374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes253Z00000XAgenciesIn Home Supportive Care