Provider Demographics
NPI:1649463753
Name:BOULET, MONIQUE S (RD)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:S
Last Name:BOULET
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 1:23 TRINITY ROCK RD
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-6603
Mailing Address - Country:US
Mailing Address - Phone:518-312-6309
Mailing Address - Fax:
Practice Address - Street 1:23 TRINITY ROCK RD
Practice Address - Street 2:
Practice Address - City:LAKE GEORGE
Practice Address - State:NY
Practice Address - Zip Code:12845-6603
Practice Address - Country:US
Practice Address - Phone:518-312-6309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY844475133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered