Provider Demographics
NPI:1942848072
Name:EIDE, ANNA SIGRID (RD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:SIGRID
Last Name:EIDE
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7361
Mailing Address - Fax:
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-739-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered