Healthcare Provider Details

I. General information

NPI: 1760156152
Provider Name (Legal Business Name): JENNIFER LISA ANTHONY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N RAYMOND ST
BOISE ID
83704-9251
US

IV. Provider business mailing address

777 N RAYMOND ST
BOISE ID
83704-9251
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-2500
  • Fax:
Mailing address:
  • Phone: 208-514-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberD-1017
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: