Provider Demographics
NPI:1396987376
Name:BOLTON, KYSKIE (RD)
Entity type:Individual
Prefix:
First Name:KYSKIE
Middle Name:
Last Name:BOLTON
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 1:272 CALHOUN STATION PARKWAY
Mailing Address - Street 2:SUITE C #1199
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-573-6667
Mailing Address - Fax:
Practice Address - Street 1:272 CALHOUN STATION PARKWAY STE C
Practice Address - Street 2:#1199
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-573-6667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-06
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1245133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06381069Medicaid