Healthcare Provider Details

I. General information

NPI: 1124049135
Provider Name (Legal Business Name): GINA ELIZABETH BOUCHETTE MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA ELIZABETH FOLTZ MS, RD

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S LINCOLN AVE
LEBANON PA
17042-7529
US

IV. Provider business mailing address

217 HIGH ST RURAL
LEBANON PA
17042-9026
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-6621
  • Fax: 717-228-6002
Mailing address:
  • Phone: 724-840-2046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN003543
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: