Provider Demographics
NPI:1346767746
Name:POULSEN, SARA ELIZABETH (RDN, LD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:POULSEN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3425
Mailing Address - Country:US
Mailing Address - Phone:208-424-0179
Mailing Address - Fax:
Practice Address - Street 1:147 STANFORD AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3425
Practice Address - Country:US
Practice Address - Phone:208-424-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-897133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered