Provider Demographics
NPI:1275222549
Name:BOUTCHER, AUDREY (RDN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BOUTCHER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 DEVON RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX FELLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07021-1716
Mailing Address - Country:US
Mailing Address - Phone:201-953-2693
Mailing Address - Fax:
Practice Address - Street 1:169 DEVON RD
Practice Address - Street 2:
Practice Address - City:ESSEX FELLS
Practice Address - State:NJ
Practice Address - Zip Code:07021-1716
Practice Address - Country:US
Practice Address - Phone:201-953-2693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered