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General NPI Number Information
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NPI Number | 1124881545
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Entity Type | Organization
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Legal Business Name | EARTHSOUL NUTRITION THERAPY PLLC
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Dates
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Enumeration Date | 01/31/2024
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 15 BRAMHALL ST APT 4
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City | PORTLAND
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State | ME
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Zip | 04102-3122
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Country | US
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Telephone | 603-793-3221
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Fax |
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Provider Business Mailing Address
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Address Line | 15 BRAMHALL ST APT 4
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City | PORTLAND
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State | ME
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Zip | 04102-3122
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Country | US
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Telephone | 603-793-3221
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Fax |
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Authorized Official
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Title or Position | CO-FOUNDER
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Name | ALEXANDRA FIERROS
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Credential | RD
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Telephone | 603-545-1553
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State |
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