Provider Demographics
NPI:1932591542
Name:BUBOLTZ, LAUREN (RDN/LDN)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BUBOLTZ
Suffix:
Gender:F
Credentials:RDN/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 KEISLER DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:547 KEISLER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-9309
Practice Address - Country:US
Practice Address - Phone:919-391-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2015-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004120133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered