Provider Demographics
NPI:1477240935
Name:LIDDELL, HEATHER DAWN (RDN, LD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:LIDDELL
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 1:5689 W MONTAGE CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7438
Mailing Address - Country:US
Mailing Address - Phone:206-954-4464
Mailing Address - Fax:
Practice Address - Street 1:13900 W WAINWRIGHT DR STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5028
Practice Address - Country:US
Practice Address - Phone:208-433-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1362133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered