Provider Demographics
NPI:1114177227
Name:REGINA, AMY BOLTZ (RD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BOLTZ
Last Name:REGINA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:BOLTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:52 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2338
Mailing Address - Country:US
Mailing Address - Phone:201-994-5498
Mailing Address - Fax:
Practice Address - Street 1:52 JOHN ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2338
Practice Address - Country:US
Practice Address - Phone:201-994-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001274133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist