Provider Demographics
NPI:1811519051
Name:HERDELL, JOSETTE (LDN, CNS)
Entity type:Individual
Prefix:
First Name:JOSETTE
Middle Name:
Last Name:HERDELL
Suffix:
Gender:F
Credentials:LDN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3183 S BONNELL RD
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6877
Mailing Address - Country:US
Mailing Address - Phone:619-718-1928
Mailing Address - Fax:
Practice Address - Street 1:3183 S BONNELL RD
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6877
Practice Address - Country:US
Practice Address - Phone:619-718-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4919133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education