Healthcare Provider Details

I. General information

NPI: 1124881545
Provider Name (Legal Business Name): EARTHSOUL NUTRITION THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BRAMHALL ST APT 4
PORTLAND ME
04102-3122
US

IV. Provider business mailing address

15 BRAMHALL ST APT 4
PORTLAND ME
04102-3122
US

V. Phone/Fax

Practice location:
  • Phone: 603-793-3221
  • Fax:
Mailing address:
  • Phone: 603-793-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA FIERROS
Title or Position: CO-FOUNDER
Credential: RD
Phone: 603-545-1553