Provider Demographics
NPI:1922547892
Name:BROCK, ANNE (RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:
Last Name:BROCK
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 FAIRVIEW AVE
Mailing Address - Street 2:SUITE 440A
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5407
Mailing Address - Country:US
Mailing Address - Phone:208-402-0636
Mailing Address - Fax:208-402-0124
Practice Address - Street 1:1906 FAIRVIEW AVE
Practice Address - Street 2:SUITE 440A
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5407
Practice Address - Country:US
Practice Address - Phone:208-402-0636
Practice Address - Fax:208-402-0124
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID86046804133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered