Provider Demographics
NPI:1225562002
Name:MILLER, CALLIE (MHS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:MHS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 HOLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2907
Mailing Address - Country:US
Mailing Address - Phone:208-871-8755
Mailing Address - Fax:888-462-8913
Practice Address - Street 1:1200 HOLMAN AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2907
Practice Address - Country:US
Practice Address - Phone:208-871-8755
Practice Address - Fax:888-462-8913
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-912133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered