Provider Demographics
NPI:1922208198
Name:BOUQUOT, CAROLYN JOSEPH (RD, LD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JOSEPH
Last Name:BOUQUOT
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 BRADFORD WAY
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-3901
Mailing Address - Country:US
Mailing Address - Phone:330-554-9327
Mailing Address - Fax:
Practice Address - Street 1:9205 STATE ROUTE 43 STE 106
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5366
Practice Address - Country:US
Practice Address - Phone:330-554-9327
Practice Address - Fax:330-294-5651
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4344133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0205731Medicaid