Provider Demographics
NPI:1659891521
Name:MALCOLM-THERIAULT, EVETHA (RD)
Entity Type:Individual
Prefix:
First Name:EVETHA
Middle Name:
Last Name:MALCOLM-THERIAULT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 MINNEQUA AVE RM 4206
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3733
Mailing Address - Country:US
Mailing Address - Phone:719-557-5955
Mailing Address - Fax:719-557-5988
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:ST. MARY-CORWIN MEDICAL CENTER /DIABETES HEALTH CENTER
Practice Address - City:PUEBLO, CO 81004
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-557-5955
Practice Address - Fax:719-557-5988
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKDTND346133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered