MEDICARE: MS. ANNETTE MARIE BOULDEN RD,MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1629254016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANNETTE MARIE BOULDEN RD,MA

Provider Business Mailing Address
First Line	:	2403 YARMOUTH LN
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-6262
Country	:	US
Telephone Number	:	609-744-4034
Fax Number	:

Provider Business Practice Location Address
First Line	:	2403 YARMOUTH LN
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-6262
Country	:	US
Telephone Number	:	609-744-4034
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2008
Last Update Date	:	05/11/2020

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