Provider Demographics
NPI:1871810507
Name:ANDERSON, SHARON L (RD)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:L
Last Name:ANDERSON
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 1:110 E WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2948
Mailing Address - Country:US
Mailing Address - Phone:208-966-4512
Mailing Address - Fax:
Practice Address - Street 1:110 E WALLACE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2948
Practice Address - Country:US
Practice Address - Phone:208-966-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60098714133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered