Healthcare Provider Details

I. General information

NPI: 1740605740
Provider Name (Legal Business Name): JOANNA BORK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST SUITE 200
BOISE ID
83712-6267
US

IV. Provider business mailing address

624 N GLEN ASPEN WAY
STAR ID
83669-5755
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7081
  • Fax:
Mailing address:
  • Phone: 208-484-2523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD-288
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: