Provider Demographics
NPI:1851683056
Name:BLANCHET, MEDINA E (RD)
Entity Type:Individual
Prefix:
First Name:MEDINA
Middle Name:E
Last Name:BLANCHET
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 1:12747 N 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9334
Mailing Address - Country:US
Mailing Address - Phone:208-391-3353
Mailing Address - Fax:208-229-7014
Practice Address - Street 1:13900 W WAINWRIGHT DR STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5028
Practice Address - Country:US
Practice Address - Phone:208-433-9424
Practice Address - Fax:844-833-5686
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-741133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD-741OtherDIETITIAN LICENSE