Provider Demographics
NPI:1477211548
Name:PORTER-BOLTON, SUZANNE (RDN)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:PORTER-BOLTON
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 1:5812 PRINCESS JEANNE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5247
Mailing Address - Country:US
Mailing Address - Phone:505-336-1211
Mailing Address - Fax:
Practice Address - Street 1:5812 PRINCESS JEANNE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5247
Practice Address - Country:US
Practice Address - Phone:505-336-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1417133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered