Healthcare Provider Details

I. General information

NPI: 1508477027
Provider Name (Legal Business Name): AMBER MARIE HISE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2020
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 SHETLER DR
COLEVILLE CA
96107-9758
US

IV. Provider business mailing address

71 SHETLER DR
COLEVILLE CA
96107-9758
US

V. Phone/Fax

Practice location:
  • Phone: 208-916-6233
  • Fax:
Mailing address:
  • Phone: 208-916-6233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1089658
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: