Provider Demographics
NPI:1912238049
Name:RAE, ERIN M (RD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:M
Last Name:RAE
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 1:2200 WARM SPRINGS AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-8429
Mailing Address - Country:US
Mailing Address - Phone:208-331-7000
Mailing Address - Fax:208-331-7080
Practice Address - Street 1:2200 WARM SPRINGS AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-8429
Practice Address - Country:US
Practice Address - Phone:208-331-7000
Practice Address - Fax:208-331-7080
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-388133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered