Basic Information
| Provider Information | |||||||||
| NPI: | 1346665189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RDN, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 HOPE DR BLDG 6000 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME AFB | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836481062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088287297 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 90 HOPE DR BLDG 6000 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME AFB | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836481062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088287297 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | D-319 | ID | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.