Provider Demographics
NPI:1750005393
Name:REYNOLDS, MIRANDA ROBERTSON (RD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROBERTSON
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E CEDAR PINE CT APT 21
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4605
Mailing Address - Country:US
Mailing Address - Phone:208-260-2467
Mailing Address - Fax:
Practice Address - Street 1:804 E CEDAR PINE CT APT 21
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4605
Practice Address - Country:US
Practice Address - Phone:208-260-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered