Provider Demographics
NPI:1457042558
Name:BEEBE, AMBER LYN (RDN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LYN
Last Name:BEEBE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:LYN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7303
Practice Address - Country:US
Practice Address - Phone:208-381-8330
Practice Address - Fax:208-381-1600
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10208007133V00000X
IDD-1414133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered