Provider Demographics
NPI:1073959193
Name:DAMMARELL, LYNN MARIE (RD,CDE,LD)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:DAMMARELL
Suffix:
Gender:F
Credentials:RD,CDE,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N CURTIS RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1337
Mailing Address - Country:US
Mailing Address - Phone:208-367-6130
Mailing Address - Fax:208-367-7313
Practice Address - Street 1:1000 N CURTIS RD
Practice Address - Street 2:SUITE 305
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1337
Practice Address - Country:US
Practice Address - Phone:208-367-6130
Practice Address - Fax:208-367-7313
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-156133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered