Provider Demographics
NPI:1487377610
Name:BALSAMO, JULIE (MS, RDN)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BALSAMO
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 US HIGHWAY 89
Mailing Address - Street 2:PO BOX #4010
Mailing Address - City:ALPINE
Mailing Address - State:WY
Mailing Address - Zip Code:83128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:317 SNAKE RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:WY
Practice Address - Zip Code:83128
Practice Address - Country:US
Practice Address - Phone:845-825-9458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86067740133VN1006X, 133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management