Provider Demographics
NPI:1033493606
Name:BOULAS, MARIAM (MS RD)
Entity Type:Individual
Prefix:MISS
First Name:MARIAM
Middle Name:
Last Name:BOULAS
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 MONTELLANO AVE
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-4805
Mailing Address - Country:US
Mailing Address - Phone:310-592-5368
Mailing Address - Fax:
Practice Address - Street 1:43112 15TH ST W # 93534
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6219
Practice Address - Country:US
Practice Address - Phone:661-726-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA999205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered