Provider Demographics
NPI:1902827207
Name:BOLDUC, LYNN M (MS, RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:MS, 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 1:43 WHITING HILL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412
Mailing Address - Country:US
Mailing Address - Phone:207-973-7334
Mailing Address - Fax:207-973-7424
Practice Address - Street 1:905 UNION ST
Practice Address - Street 2:SUITE 11
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3050
Practice Address - Country:US
Practice Address - Phone:207-973-7334
Practice Address - Fax:207-973-7424
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT0191Medicare ID - Type Unspecified