MEDICARE: MRS. CIERRA NICOLE NEIWERT RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DI60685770	WA
2	133V00000X	Registered Dietitian	D1052	ID

General Provider Information

NPI Number	:	1144778309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CIERRA NICOLE NEIWERT RDN

Provider Business Mailing Address
First Line	:	175 E HAWTHORN PKWY STE 235
Second Line	:
City	:	VERNON HILLS
State	:	IL
Zip	:	60061-1454
Country	:	US
Telephone Number	:	847-737-8768
Fax Number	:	847-859-5885

Provider Business Practice Location Address
First Line	:	1859 S TOPAZ WAY STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-4401
Country	:	US
Telephone Number	:	208-209-2432
Fax Number	:	848-859-5885

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2016
Last Update Date	:	01/10/2019

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