Provider Demographics
NPI:1962783209
Name:MILLS, PAMELA (RD,LD,CDE)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N 200 W
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-1239
Mailing Address - Country:US
Mailing Address - Phone:208-766-2231
Mailing Address - Fax:208-766-4819
Practice Address - Street 1:150 N 200 W
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1239
Practice Address - Country:US
Practice Address - Phone:208-766-2231
Practice Address - Fax:208-766-4819
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-313133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered