Provider Demographics
NPI:1821275942
Name:BOUCHIE, KARISSA ANNE (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:ANNE
Last Name:BOUCHIE
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1324
Mailing Address - Country:US
Mailing Address - Phone:559-253-3748
Mailing Address - Fax:
Practice Address - Street 1:2823 FRESNO STREET
Practice Address - Street 2:COMMUNITY REGIONAL MEDICAL CENTER
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701
Practice Address - Country:US
Practice Address - Phone:559-459-2882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2279133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered