Provider Demographics
NPI:1174368658
Name:BOULWARE, IESHA
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:
Last Name:BOULWARE
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 1:9414 LAKELAND FELLS LN
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-5016
Mailing Address - Country:US
Mailing Address - Phone:703-371-7456
Mailing Address - Fax:
Practice Address - Street 1:9414 LAKELAND FELLS LN
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-5016
Practice Address - Country:US
Practice Address - Phone:703-371-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)