Healthcare Provider Details

I. General information

NPI: 1003996398
Provider Name (Legal Business Name): TENNILLE IRENE HOUSTON MHE, RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HILAND AVE CASSIA REGIONAL MEDICAL CENTER
BURLEY ID
83318-2682
US

IV. Provider business mailing address

278 DOLLAR HIDE WAY
JEROME ID
83338-6554
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-6587
  • Fax:
Mailing address:
  • Phone: 208-731-8789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-348
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: