Basic Information
| Provider Information | |||||||||
| NPI: | 1164540209 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JEANNEE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6516 W OUTLOOK DR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837145402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088533815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1226 W RIVER ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837027049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083111155 | ||||||||
| FaxNumber: | 2083830190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | D-146 | ID | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.