Provider Demographics
NPI:1871189902
Name:ANSPACH, MIRANDA (RD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:ANSPACH
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 1:2909 N 4TH ST APT 16
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6031
Mailing Address - Country:US
Mailing Address - Phone:208-310-3136
Mailing Address - Fax:
Practice Address - Street 1:2909 N 4TH ST APT 16
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-6031
Practice Address - Country:US
Practice Address - Phone:208-310-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1113133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty