Provider Demographics
NPI:1578981015
Name:BOSTAIN, RENEE LYNN (RD, LD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:LYNN
Last Name:BOSTAIN
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 1:2501 N ORANGE AVE STE 509
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4674
Mailing Address - Country:US
Mailing Address - Phone:407-303-9840
Mailing Address - Fax:407-303-1573
Practice Address - Street 1:2501 N ORANGE AVE STE 509
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4674
Practice Address - Country:US
Practice Address - Phone:407-303-9840
Practice Address - Fax:407-303-1573
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5622133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered