Provider Demographics
NPI:1295145654
Name:KIPP, SANDRA (RDN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:KIPP
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 W MOUNTAIN ASH LOOP
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2681
Mailing Address - Country:US
Mailing Address - Phone:208-250-0836
Mailing Address - Fax:888-972-6280
Practice Address - Street 1:1105 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3911
Practice Address - Country:US
Practice Address - Phone:208-250-0836
Practice Address - Fax:888-972-6280
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-789133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered