Provider Demographics
NPI:1619593449
Name:CONRAD, AUDREY (MS, RDN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16924 FOOTHILL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8298
Mailing Address - Country:US
Mailing Address - Phone:907-382-1420
Mailing Address - Fax:
Practice Address - Street 1:16924 FOOTHILL AVE APT 3
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8298
Practice Address - Country:US
Practice Address - Phone:307-761-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK86100931133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered