Provider Demographics
NPI:1124049135
Name:BOUCHETTE, GINA ELIZABETH (MS, RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:ELIZABETH
Last Name:BOUCHETTE
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:MISS
Other - First Name:GINA
Other - Middle Name:ELIZABETH
Other - Last Name:FOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:217 HIGH ST RURAL
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-9026
Mailing Address - Country:US
Mailing Address - Phone:724-840-2046
Mailing Address - Fax:
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-6002
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003543133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered