Provider Demographics
NPI:1740041268
Name:NOURISHED BODY
Entity type:Organization
Organization Name:NOURISHED BODY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRACCIANO
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:208-819-8413
Mailing Address - Street 1:1321 N NORTHWOOD CENTER CT STE B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4944
Mailing Address - Country:US
Mailing Address - Phone:208-819-8413
Mailing Address - Fax:
Practice Address - Street 1:1321 N NORTHWOOD CENTER CT STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4944
Practice Address - Country:US
Practice Address - Phone:208-819-8413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1497221220OtherTIN