Provider Demographics
NPI:1295150738
Name:ERICKSON, MARISA (RD, LD)
Entity type:Individual
Prefix:MS
First Name:MARISA
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13307 MIAMI LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-4701
Mailing Address - Country:US
Mailing Address - Phone:208-455-5335
Mailing Address - Fax:208-455-5443
Practice Address - Street 1:13307 MIAMI LN
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-4701
Practice Address - Country:US
Practice Address - Phone:208-455-5335
Practice Address - Fax:208-455-5443
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-801133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered