Basic Information
| Provider Information | |||||||||
| NPI: | 1790224699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLIN | ||||||||
| FirstName: | CRISTINA | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | DNP APRNC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 9880 ANGIES WAY | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402412851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026295400 | ||||||||
| FaxNumber: | 5026295492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3011085 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 24728 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 50125255 | 01 | KY | PASSPORT | OTHER | 226541 | 01 | KY | SIHO | OTHER | 000001074358 | 01 | KY | ANTHEM | OTHER | 7100471030 | 05 | KY | MEDICAID | K218100 | 01 | KY | MEDICARE | OTHER |