Healthcare Provider Details

I. General information

NPI: 1114656907
Provider Name (Legal Business Name): NORTHWEST NUTRITION CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 W IRONWOOD DR # 1005
COEUR D ALENE ID
83814-2640
US

IV. Provider business mailing address

206 W IRONWOOD DR STE 1005
COEUR D ALENE ID
83814-2640
US

V. Phone/Fax

Practice location:
  • Phone: 208-719-2921
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: REBEKAH TAGUE
Title or Position: OWNER
Credential:
Phone: 208-906-2208