Provider Demographics
NPI:1801352083
Name:OWENS, MIKYAH HOPE (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:MIKYAH
Middle Name:HOPE
Last Name:OWENS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E COEUR D ALENE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4180
Mailing Address - Country:US
Mailing Address - Phone:208-215-8727
Mailing Address - Fax:
Practice Address - Street 1:1415 E COEUR D ALENE AVE APT 1
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4180
Practice Address - Country:US
Practice Address - Phone:208-215-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered