Provider Demographics
NPI:1922431345
Name:ROBERTS, MISTY A (RD,LD)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:A
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 E TERRY ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2733
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-236-6695
Practice Address - Street 1:2302 E TERRY ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2733
Practice Address - Country:US
Practice Address - Phone:208-236-1600
Practice Address - Fax:208-236-6695
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD777133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered