=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508477027
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMBER MARIE HISE RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2020
-----------------------------------------------------
Last Update Date | 08/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 SHETLER DR
-----------------------------------------------------
City | COLEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96107-9758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-916-6233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 71 SHETLER DR
-----------------------------------------------------
City | COLEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96107-9758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-916-6233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 1089658
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------