Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CHIA829 | ID |
NPI | 1093718702 |
---|---|
Provider Name | Dr. Shannon Dee Gaertner-Ewing |
First Address | Nampa, ID 83653-3306 |
Second Address | Nampa, ID 83651-3848 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U65584 | (02) | ID |