Provider Demographics
NPI:1659655629
Name:BOLDEN, HEATHER NICOLE (NP-C)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:NICOLE
Last Name:BOLDEN
Suffix:
Gender:
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 VAN AALST BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2102
Mailing Address - Country:US
Mailing Address - Phone:762-408-1418
Mailing Address - Fax:762-408-8156
Practice Address - Street 1:6600 VAN AALST BLVD
Practice Address - Street 2:MARTIN ARMY COMMUNITY HOSPITAL-DPH
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:762-408-1418
Practice Address - Fax:762-408-8156
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175548363LX0106X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF0911414OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION PROGRAM
GAF0911414OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION PROGRAM