Provider Demographics
NPI:1154690543
Name:DAVIDSON, JOANNA KELLEY (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:KELLEY
Last Name:DAVIDSON
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 1:777 HOSPITAL WAY
Mailing Address - Street 2:BUILDING A, SUITE 201
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-239-2737
Mailing Address - Fax:208-239-3778
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:BUILDING A, SUITE 201
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2737
Practice Address - Fax:208-239-3778
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-333133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered