Provider Demographics
NPI:1649724865
Name:BOOTHBY, JOAN
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:BOOTHBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3329
Mailing Address - Country:US
Mailing Address - Phone:909-596-4879
Mailing Address - Fax:909-596-9199
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3329
Practice Address - Country:US
Practice Address - Phone:909-596-4879
Practice Address - Fax:909-596-9199
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education