Healthcare Provider Details

I. General information

NPI: 1235665290
Provider Name (Legal Business Name): SHARON NELSON RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2790 S GOSHEN WAY
BOISE ID
83709
US

IV. Provider business mailing address

2790 S GOSHEN WAY
BOISE ID
83709-8506
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-7975
  • Fax:
Mailing address:
  • Phone: 208-373-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-254
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: