Provider Demographics
NPI:1972175511
Name:BOLTMAN, CASSANDRA
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:BOLTMAN
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 1:12 AUSTIN ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHANNESBURG
Mailing Address - State:GAUTENG
Mailing Address - Zip Code:01685
Mailing Address - Country:GS
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-2516
Practice Address - Country:US
Practice Address - Phone:305-348-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
00000000002255A2300X
FL00000000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6314201OtherFIU ID