Provider Demographics
NPI:1992296669
Name:BOLTEN, ADRIENNE
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:BOLTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:TILLSON
Mailing Address - State:NY
Mailing Address - Zip Code:12486-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 ROUTE 55
Practice Address - Street 2:
Practice Address - City:LAGRANGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12540-5108
Practice Address - Country:US
Practice Address - Phone:845-475-9660
Practice Address - Fax:845-475-9938
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered