Healthcare Provider Details

I. General information

NPI: 1225423262
Provider Name (Legal Business Name): SERENA ARAVE RD, CNSC, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 E OLD SAYBROOK DR
BOISE ID
83706-4920
US

IV. Provider business mailing address

267 E OLD SAYBROOK DR
BOISE ID
83706-4920
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-7198
  • Fax:
Mailing address:
  • Phone: 208-342-7198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD-414
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD-414
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: