Provider Demographics
NPI:1619757978
Name:BOEHNLEIN, SYDNEY RAE (MS, RD, LD, CSSD)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:RAE
Last Name:BOEHNLEIN
Suffix:
Gender:F
Credentials:MS, RD, LD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 ZEMKE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-5023
Mailing Address - Country:US
Mailing Address - Phone:813-827-9809
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86063342133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered