Provider Demographics
NPI:1689363970
Name:WALTON, SOPHIE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:MARIE
Last Name:WALTON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DORCHESTER AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1107
Mailing Address - Country:US
Mailing Address - Phone:774-208-4614
Mailing Address - Fax:
Practice Address - Street 1:825 DORCHESTER AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02125-1107
Practice Address - Country:US
Practice Address - Phone:774-208-4614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN6665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered