Provider Demographics
NPI:1033343785
Name:FIELDS, DENISE K (LICENSED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:K
Last Name:FIELDS
Suffix:
Gender:F
Credentials:LICENSED DIETITIAN
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:K
Other - Last Name:BOUTWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSED DIETITIAN
Mailing Address - Street 1:733 LAKE LAURIE DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6421
Mailing Address - Country:US
Mailing Address - Phone:229-630-3833
Mailing Address - Fax:
Practice Address - Street 1:733 LAKE LAURIE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-6421
Practice Address - Country:US
Practice Address - Phone:229-630-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003359133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered