Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 5787 | OR |
NPI | 1326585670 |
---|---|
Provider Name | Mrs. Kirstin Mindy Ebaugh |
First Address | Eugene, OR 97403-1962 |
Second Address | Eugene, OR 97403-1962 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2017 |
Last Update Date | 18/09/2019 |