Provider Demographics
NPI:1477728178
Name:BOURN, BRENDA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:BOURN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:LYNN
Other - Last Name:STEINOCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:1226 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7049
Practice Address - Country:US
Practice Address - Phone:208-331-1155
Practice Address - Fax:208-383-0190
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00864302133V00000X
NM00777133V00000X
IDD-742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477728178Medicaid