Provider Demographics
NPI:1689266629
Name:MIEDEMA, KATIE MALISSA (MPH, RD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MALISSA
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MALISSA
Other - Last Name:MCCARTHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPH, RD
Mailing Address - Street 1:1740 E FAIRVIEW AVE # 99
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5702
Mailing Address - Country:US
Mailing Address - Phone:949-572-9275
Mailing Address - Fax:
Practice Address - Street 1:3000 E LUCCA DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3083
Practice Address - Country:US
Practice Address - Phone:949-572-9275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered