Basic Information
| Provider Information | |||||||||
| NPI: | 1962136184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLLING | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245715 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 CRYSTAL SPRING AVE SW STE 201 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240142465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408530100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001192587 | VA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 0024184858 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.