Provider Demographics
NPI:1689407082
Name:DURHAM, ANGELIECE NICOLE (RD)
Entity type:Individual
Prefix:
First Name:ANGELIECE
Middle Name:NICOLE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ANGELIECE
Other - Middle Name:NICOLE
Other - Last Name:GUERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2211 ALEX DR
Mailing Address - Street 2:
Mailing Address - City:FILER
Mailing Address - State:ID
Mailing Address - Zip Code:83328-5423
Mailing Address - Country:US
Mailing Address - Phone:208-830-9631
Mailing Address - Fax:
Practice Address - Street 1:2211 ALEX DR
Practice Address - Street 2:
Practice Address - City:FILER
Practice Address - State:ID
Practice Address - Zip Code:83328-5423
Practice Address - Country:US
Practice Address - Phone:208-830-9631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered