Provider Demographics
NPI:1962427658
Name:BOLLES-HOLDER, MARY T (CNM, ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:BOLLES-HOLDER
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:THERESA
Other - Last Name:BOLLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:10330 MERIDIAN AVE N
Practice Address - Street 2:SUITE 190
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9451
Practice Address - Country:US
Practice Address - Phone:206-368-6670
Practice Address - Fax:206-368-6171
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00089718163W00000X
WAAP30006303363L00000X, 367A00000X
WAAP61434065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA56102UOtherREGENCE BLUESHIELD
WA1962427658Medicaid
WA9639014Medicaid
P89832Medicare UPIN