Provider Demographics
NPI:1871355578
Name:BOLELA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOLELA
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 1:242 HOLLY HILL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-5867
Mailing Address - Country:US
Mailing Address - Phone:601-573-9458
Mailing Address - Fax:
Practice Address - Street 1:242 HOLLY HILL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-5867
Practice Address - Country:US
Practice Address - Phone:601-573-9458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS875417163W00000X
3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No163W00000XNursing Service ProvidersRegistered Nurse