Provider Demographics
NPI:1699705087
Name:DONALDSON, KAREN DIANE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:DIANE
Last Name:DONALDSON
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 W CENTER ST # 208
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4205
Mailing Address - Country:US
Mailing Address - Phone:208-406-8120
Mailing Address - Fax:208-174-4649
Practice Address - Street 1:845 W CENTER ST # 208
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4205
Practice Address - Country:US
Practice Address - Phone:208-406-1084
Practice Address - Fax:208-714-4649
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-479133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807328700Medicaid