Provider Demographics
NPI:1295768562
Name:HARSTON, RONDA K
Entity type:Individual
Prefix:
First Name:RONDA
Middle Name:K
Last Name:HARSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7542
Mailing Address - Country:US
Mailing Address - Phone:208-523-1122
Mailing Address - Fax:205-523-2582
Practice Address - Street 1:2220 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7542
Practice Address - Country:US
Practice Address - Phone:208-523-1122
Practice Address - Fax:205-523-2582
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00250149OtherRAILROAD MEDICARE
ID1940639Medicare ID - Type Unspecified