Healthcare Provider Details

I. General information

NPI: 1265773337
Provider Name (Legal Business Name): WENDY MARIE KILLIAN RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 N 3750 E
RIGBY ID
83442-5036
US

IV. Provider business mailing address

756 N 3750 E
RIGBY ID
83442-5036
US

V. Phone/Fax

Practice location:
  • Phone: 208-244-1633
  • Fax:
Mailing address:
  • Phone: 208-244-1633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-612
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: