=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225423262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SERENA ARAVE RD, CNSC, LD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 04/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 E OLD SAYBROOK DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-342-7198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 267 E OLD SAYBROOK DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-342-7198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1004X
-----------------------------------------------------
Taxonomy Name | Pediatric Nutrition Registered Dietitian
-----------------------------------------------------
License Number | D-414
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133VN1006X
-----------------------------------------------------
Taxonomy Name | Metabolic Nutrition Registered Dietitian
-----------------------------------------------------
License Number | D-414
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------