Kyle Bolton

Primary specialty

Registered DietitianTaxonomy code 133V00000X

Practice address

20460 Anaconda Rd
Fort Drum, NY 13603

Phone

(480) 387-0619

NPI assigned

Dec 13, 2021

Last updated

Mar 18, 2025By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1639353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1742256000000",
    "number": "1861151326",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20460 ANACONDA RD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "13603",
            "telephone_number": "480-387-0619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20460 ANACONDA RD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "13603",
            "telephone_number": "480-387-0619"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOLTON",
        "first_name": "KYLE",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-12-13",
        "last_updated": "2025-03-18",
        "certification_date": "2025-03-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "133V00000X",
            "taxonomy_group": "",
            "desc": "Dietitian, Registered",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Bobbi Petranchuk
• Heidi L Boerman, PA-C, ATC
• Laura Marie Boff, LISW-CP
• Jillisa Boller, DENTAL ASSISTANT X2
• Justine Noel Bolten, OTD, OTR/L
• Jessica Lynn Bondy-Carey, D.M.D.
• Don Bonham, LMSW, CASAC
• Carlos Bou Assi, DMD
• Kyle P Bourque, LISW
• Jane Bowers, R.D.H.

• Registered Dietitian in Fort Drum, NY
• Providers in Fort Drum, NY by specialty
• Registered Dietitian in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.