Provider Demographics
NPI:1093571739
Name:WILTSE, EVELYN CLAIRE (RD, LD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:CLAIRE
Last Name:WILTSE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W RM H1155
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5810
Practice Address - Country:US
Practice Address - Phone:208-814-1016
Practice Address - Fax:208-814-7212
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1581133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered