Provider Demographics
NPI:1295489532
Name:BOUGHTON, KATHLEEN GREENE (RD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GREENE
Last Name:BOUGHTON
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 1:3637 ROLRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7656
Mailing Address - Country:US
Mailing Address - Phone:804-647-6177
Mailing Address - Fax:
Practice Address - Street 1:3637 ROLRIDGE RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7656
Practice Address - Country:US
Practice Address - Phone:804-647-6177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA887800133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered