Provider Demographics
NPI:1649990441
Name:BOEKEN, AUDREY LYNN (RD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LYNN
Last Name:BOEKEN
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 1:942 N REDBUD CT
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67147-3215
Mailing Address - Country:US
Mailing Address - Phone:785-531-0739
Mailing Address - Fax:
Practice Address - Street 1:929 N ST FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-777-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2690133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered