Provider Demographics
NPI:1174890784
Name:BOLDIN, ASHLEY R (CPHT)
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:R
Last Name:BOLDIN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 1ST AVE SW
Mailing Address - Street 2:#908
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3314
Mailing Address - Country:US
Mailing Address - Phone:501-772-4399
Mailing Address - Fax:
Practice Address - Street 1:318 1ST AVE SW
Practice Address - Street 2:#908
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-3314
Practice Address - Country:US
Practice Address - Phone:501-772-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN723951183700000X
CA109606183700000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No183700000XPharmacy Service ProvidersPharmacy Technician