Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 67009 | ID |
NPI | 1013504836 |
---|---|
Provider Name | Angela Stanger |
First Address | Twin Falls, ID 83301-3455 |
Second Address | Twin Falls, ID 83301-3455 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2020 |
Last Update Date | 17/01/2021 |