Healthcare Provider Details

I. General information

NPI: 1801218359
Provider Name (Legal Business Name): KRISTA BROWN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

8860 W EVENING STAR LN
BOISE ID
83709-5306
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-603
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: