Healthcare Provider Details

I. General information

NPI: 1053010397
Provider Name (Legal Business Name): STORMI NIEMANN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86290639
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1328
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: