Provider Demographics
NPI:1225064074
Name:BOYSEN, NICOLE L (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BOYSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 WEBER ROAD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640
Mailing Address - Country:US
Mailing Address - Phone:573-756-4581
Mailing Address - Fax:573-756-5834
Practice Address - Street 1:1212 WEBER ROAD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-756-4581
Practice Address - Fax:573-756-5834
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006008944133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered