Provider Demographics
NPI:1033544580
Name:WILSON, ABBY JAN (RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:JAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:JAN
Other - Last Name:GUSTAVESON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD, CDE
Mailing Address - Street 1:957 HOSPITAL WAY BLDG D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5096
Mailing Address - Country:US
Mailing Address - Phone:208-239-2070
Mailing Address - Fax:
Practice Address - Street 1:957 HOSPITAL WAY BLDG D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5096
Practice Address - Country:US
Practice Address - Phone:208-239-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002152133V00000X
IDD-795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1134168263OtherHOSPITAL NPI#
ID1790751055OtherHOSPITAL NPI#