Provider Demographics
NPI:1134224421
Name:BROTHER, MARY ANN (RD)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:BROTHER
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 1:4443 MACKENZIE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703
Mailing Address - Country:US
Mailing Address - Phone:208-422-1141
Mailing Address - Fax:
Practice Address - Street 1:500 WEST FORT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-092133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered