Provider Demographics
NPI:1003823238
Name:BOUQUET, STEPHANIE (MS, RD, CDE)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BOUQUET
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18420 WILDROSE CT
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93908-1542
Mailing Address - Country:US
Mailing Address - Phone:831-809-9725
Mailing Address - Fax:
Practice Address - Street 1:110 JOHN ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3321
Practice Address - Country:US
Practice Address - Phone:831-809-9725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARD727246133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP63301Medicare UPIN
CAZZZ23838ZMedicare ID - Type Unspecified