Basic Information
| Provider Information | |||||||||
| NPI: | 1477728178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURN | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEINOCKER | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1226 W RIVER ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837027049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083311155 | ||||||||
| FaxNumber: | 2083830190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 00864302 | AZ | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 00777 | NM | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | D-742 | ID | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1477728178 | 05 | ID | MEDICAID |