Provider Demographics
NPI:1447081773
Name:BOULLION, LANIE RENEE
Entity type:Individual
Prefix:
First Name:LANIE
Middle Name:RENEE
Last Name:BOULLION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16733 W LA HWY 700
Mailing Address - Street 2:
Mailing Address - City:KAPLAN
Mailing Address - State:LA
Mailing Address - Zip Code:70548-6454
Mailing Address - Country:US
Mailing Address - Phone:337-652-1669
Mailing Address - Fax:
Practice Address - Street 1:16733 W LA HWY 700
Practice Address - Street 2:
Practice Address - City:KAPLAN
Practice Address - State:LA
Practice Address - Zip Code:70548-6454
Practice Address - Country:US
Practice Address - Phone:337-652-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3197133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered