Basic Information
| Provider Information | |||||||||
| NPI: | 1386194520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOYLAN | ||||||||
| FirstName: | ALEXEI | ||||||||
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| Credential: | MS, RDN, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 S WILKES BARRE BLVD | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187025040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708292621 | ||||||||
| FaxNumber: | 5708234332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 133V00000X | DN006281 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.