Provider Demographics
NPI:1699456491
Name:BOLESKA, SZANDRA BARBARA (RD, LD)
Entity type:Individual
Prefix:
First Name:SZANDRA
Middle Name:BARBARA
Last Name:BOLESKA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:SZANDRA
Other - Middle Name:
Other - Last Name:RUGGLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11412 MALAGUENA LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6898
Mailing Address - Country:US
Mailing Address - Phone:757-775-1517
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4917
Practice Address - Country:US
Practice Address - Phone:505-563-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNDP-2023-0005133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered