Provider Demographics
NPI:1184452229
Name:HARRIS, ETHAN MALACHI (RDN, LDN)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:MALACHI
Last Name:HARRIS
Suffix:
Gender:M
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7824 KANIS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-2307
Mailing Address - Country:US
Mailing Address - Phone:501-615-3869
Mailing Address - Fax:
Practice Address - Street 1:7824 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2307
Practice Address - Country:US
Practice Address - Phone:501-615-3869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR86169227133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered