Provider Demographics
NPI:1154629574
Name:BOOTH, CAROL LYNN (RD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-3865
Mailing Address - Country:US
Mailing Address - Phone:814-288-5801
Mailing Address - Fax:
Practice Address - Street 1:415 MARGARET AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-3865
Practice Address - Country:US
Practice Address - Phone:814-288-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001771133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered