Healthcare Provider Details

I. General information

NPI: 1588237952
Provider Name (Legal Business Name): VALERIE OLIVIA BRANSON RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S MAIN ST
MOSCOW ID
83843-3046
US

IV. Provider business mailing address

PO BOX 8007
MOSCOW ID
83843-0507
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-4511
  • Fax:
Mailing address:
  • Phone: 208-883-2224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI61176227
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-1363
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: