Provider Demographics
NPI:1043298847
Name:EEN, MIRIAM B (RD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:B
Last Name:EEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 FIRE MESA ST
Mailing Address - Street 2:#180, FAMILY PRACTICE CENTER
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9016
Mailing Address - Country:US
Mailing Address - Phone:702-992-6888
Mailing Address - Fax:702-992-6880
Practice Address - Street 1:1524 PINTO LN FL 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4195
Practice Address - Country:US
Practice Address - Phone:702-992-6888
Practice Address - Fax:702-992-6880
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16273133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500816Medicaid
NVWQBHV37820Medicare ID - Type Unspecified