Provider Demographics
NPI:1124183090
Name:BOLTON, ELLEN JEAN (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:JEAN
Last Name:BOLTON
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18310 W 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-6552
Mailing Address - Country:US
Mailing Address - Phone:913-888-2714
Mailing Address - Fax:
Practice Address - Street 1:20333 W 151ST ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5350
Practice Address - Country:US
Practice Address - Phone:913-791-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1062133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered