Provider Demographics
NPI:1922432277
Name:BOLEY, GEORGIA FLETCHER (MS,RD,LD,CSO)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:FLETCHER
Last Name:BOLEY
Suffix:
Gender:F
Credentials:MS,RD,LD,CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 BOX CROSS RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-9020
Mailing Address - Country:US
Mailing Address - Phone:307-752-8213
Mailing Address - Fax:307-675-1866
Practice Address - Street 1:211 SMITH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3818
Practice Address - Country:US
Practice Address - Phone:307-752-8213
Practice Address - Fax:307-675-1866
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT87227133V00000X
WY084133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY156924Medicaid