Healthcare Provider Details

I. General information

NPI: 1659754810
Provider Name (Legal Business Name): SHANNON LEIAMBRE STAMPER RD, CSP, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON LEIAMBRE MORGAN RD, CSP, LD

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 W HAYS ST
BOISE ID
83702
US

IV. Provider business mailing address

610 W HAYS ST
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7092
  • Fax: 208-381-7071
Mailing address:
  • Phone: 208-381-7092
  • Fax: 208-381-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-874
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD-874
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: