Provider Demographics
NPI:1366912529
Name:BOLDEN, CARISSA MARTINE (NP)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARTINE
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SELLERS ST
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-8743
Mailing Address - Country:US
Mailing Address - Phone:601-528-0203
Mailing Address - Fax:
Practice Address - Street 1:249 BEAUVOIR RD STE B2
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4008
Practice Address - Country:US
Practice Address - Phone:601-283-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily