Provider Demographics
NPI:1871275826
Name:BOLIEK-GELB, KASSIDY MARIE
Entity type:Individual
Prefix:
First Name:KASSIDY
Middle Name:MARIE
Last Name:BOLIEK-GELB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASSIDY
Other - Middle Name:MARIE
Other - Last Name:BOLIEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3407 GRAY WHETSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7792
Mailing Address - Country:US
Mailing Address - Phone:352-255-8964
Mailing Address - Fax:
Practice Address - Street 1:11948 BALM RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-6601
Practice Address - Country:US
Practice Address - Phone:813-236-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027823363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics