Provider Demographics
NPI:1548576234
Name:SPAIN, ANGELA KAY (RD)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:KAY
Last Name:SPAIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:KAY
Other - Last Name:SPAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:707 N ARMSTRONG PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-0825
Mailing Address - Country:US
Mailing Address - Phone:208-327-8545
Mailing Address - Fax:
Practice Address - Street 1:707 N ARMSTRONG PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0825
Practice Address - Country:US
Practice Address - Phone:208-327-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD104133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered