Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CHIA 761 | ID |
NPI | 1083629448 |
---|---|
Provider Name | Dr. Sue V. Phillips |
First Address | Twin Falls, ID 83301-5343 |
Second Address | Twin Falls, ID 83301-5343 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 08/07/2007 |