Healthcare Provider Details

I. General information

NPI: 1225276777
Provider Name (Legal Business Name): MINETTE SUE RIDENOUR HERRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MINETTE SUE RIDENOUR

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673D MDG, 5955 ZEAMER AVENUE
ANCHORAGE AK
99506
US

IV. Provider business mailing address

5955 ZEAMER AVE
ANCHORAGE AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-4314
  • Fax:
Mailing address:
  • Phone: 907-508-4314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: