Provider Demographics
NPI:1003996398
Name:HOUSTON, TENNILLE IRENE (MHE, RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:IRENE
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:MHE, 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 1:278 DOLLAR HIDE WAY
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6554
Mailing Address - Country:US
Mailing Address - Phone:208-731-8789
Mailing Address - Fax:
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:CASSIA REGIONAL MEDICAL CENTER
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-677-6587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-348133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP90549Medicare UPIN