Active NPI
Penny Bolen, RD, LDN
- Registered Dietitian
- Rockford, IL
National Provider Identifier
1487941886
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- 164.001351
- Practice address
- 1401 E State St
Rockford, IL 61104-2315 - Phone
- (815) 489-4662
- Fax
- (815) 961-2438
- NPI assigned
- Jul 6, 2011
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Registered Dietitian | 133V00000X | 164.001351 | IL | Primary |
Addresses
Primary practice location
1401 E State St
Rockford, IL 61104-2315
Mailing address
6623 Valley Trail Rd
Rockford, IL 61109-4599
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 164.001351 | IL | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1309910400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1309910400000",
"number": "1487941886",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6623 VALLEY TRAIL RD",
"city": "ROCKFORD",
"state": "IL",
"postal_code": "611094599"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1401 E STATE ST",
"city": "ROCKFORD",
"state": "IL",
"postal_code": "611042315",
"telephone_number": "815-489-4662",
"fax_number": "815-961-2438"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOLEN",
"first_name": "PENNY",
"credential": "RD, LDN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2011-07-06",
"last_updated": "2011-07-06",
"status": "A"
},
"taxonomies": [
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "IL",
"license": "164.001351",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rockford, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.