Provider Demographics
NPI:1811255755
Name:USILTON, LANA M (CN)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:M
Last Name:USILTON
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 N WHITLEY DR
Mailing Address - Street 2:STE 1A
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2177
Mailing Address - Country:US
Mailing Address - Phone:208-452-4900
Mailing Address - Fax:
Practice Address - Street 1:1611 N WHITLEY DR
Practice Address - Street 2:STE 1A
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2177
Practice Address - Country:US
Practice Address - Phone:208-452-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-29
Last Update Date:2012-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist