Basic Information
| Provider Information | |||||||||
| NPI: | 1962427658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLLES-HOLDER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM, ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLLES | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | THERESA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 50095 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981455095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065205700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10330 MERIDIAN AVE N | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981339451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063686670 | ||||||||
| FaxNumber: | 2063686171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 11/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00089718 | WA | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP30006303 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | AP30006303 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 56102U | 01 | WA | REGENCE BLUESHIELD | OTHER | 9639014 | 05 | WA | MEDICAID | 1962427658 | 05 | WA | MEDICAID |