Basic Information
| Provider Information | |||||||||
| NPI: | 1225415615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDERMAN | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LDN, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLDERMAN | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | MARGARET | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RD, LDN, CDE | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N US HIGHWAY 441 | ||||||||
| Address2: | SUUITE 810 | ||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321598975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2015 | ||||||||
| LastUpdateDate: | 05/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND7205 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.