Provider Demographics
NPI:1194411447
Name:IMELLI, ANNIKA LENORE DOUGHERTY (RD, IBCLC)
Entity type:Individual
Prefix:
First Name:ANNIKA
Middle Name:LENORE DOUGHERTY
Last Name:IMELLI
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460458
Mailing Address - Street 2:
Mailing Address - City:POLARIS
Mailing Address - State:MT
Mailing Address - Zip Code:59746-0458
Mailing Address - Country:US
Mailing Address - Phone:415-606-9558
Mailing Address - Fax:
Practice Address - Street 1:141 ASPEN VIEW RD
Practice Address - Street 2:
Practice Address - City:POLARIS
Practice Address - State:MT
Practice Address - Zip Code:59746
Practice Address - Country:US
Practice Address - Phone:415-606-9558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-21954174N00000X
MTMED-NUT-LIC-125402133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN