Provider Demographics
NPI:1396895603
Name:BOL, SUSAN N (RD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:N
Last Name:BOL
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 1:269 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:UXBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01569-1130
Mailing Address - Country:US
Mailing Address - Phone:508-856-3367
Mailing Address - Fax:508-856-8020
Practice Address - Street 1:55 LAKE AVE NORTH
Practice Address - Street 2:UMMHC
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655
Practice Address - Country:US
Practice Address - Phone:508-856-3367
Practice Address - Fax:508-856-8020
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1304133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered