Provider Demographics
NPI:1659233666
Name:HUMPHREY, ANNA LOUISE (RDN)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:LOUISE
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1624
Mailing Address - Country:US
Mailing Address - Phone:208-699-5694
Mailing Address - Fax:
Practice Address - Street 1:431 S 12TH ST
Practice Address - Street 2:
Practice Address - City:SAINT MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-1624
Practice Address - Country:US
Practice Address - Phone:208-699-5694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-27
Last Update Date:2025-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1390133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered