Individual
KODY MICHAEL DUCLOS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RD, LD
Contact information
Practice address
305 E JEFFERSON ST, BOISE, ID 83712-6231
(208) 381-7081
Mailing address
5176 W MERCURY CT, BOISE, ID 83705-3746
(208) 507-5656
Taxonomy
Speciality
Code
Description
License number
State
133VN1004X
Pediatric Nutrition Registered Dietitian
Primary
86117056
ID
133VN1301X
Oncology Nutrition Registered Dietitian
86117056
ID
133VN1401X
Pediatric Critical Care Nutrition Registered Dietitian
86117056
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
86117056
COMMISSION ON DIETETIC REGISTRATION
ID
Enumeration date
04/02/2020
Last updated
04/02/2020
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