Provider Demographics
NPI:1669511358
Name:BOUTIN, DEBRA ANN (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 JUANITA DR NE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4966
Mailing Address - Country:US
Mailing Address - Phone:425-602-3124
Mailing Address - Fax:425-823-6222
Practice Address - Street 1:14500 JUANITA DR NE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-4966
Practice Address - Country:US
Practice Address - Phone:425-602-3124
Practice Address - Fax:425-823-6222
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered