Healthcare Provider Details

I. General information

NPI: 1689349433
Provider Name (Legal Business Name): ALYSON NIELSEN I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST STE 300
BOISE ID
83704-8708
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2300
  • Fax: 208-302-2355
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86071450
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1260
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: