Provider Demographics
NPI:1811471477
Name:BOUCHARD, ISABELLE M (RDN)
Entity type:Individual
Prefix:
First Name:ISABELLE
Middle Name:M
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 NE BARRY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64158-1124
Mailing Address - Country:US
Mailing Address - Phone:573-356-5261
Mailing Address - Fax:
Practice Address - Street 1:9601 NE BARRY RD STE 201
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64158-1124
Practice Address - Country:US
Practice Address - Phone:573-356-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered