Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XH1200X | Occupational Therapist - Hand | OT-209 | ID |
NPI | 1023074739 |
---|---|
Provider Name | Mrs. Cheryl E Rodnick |
First Address | Pocatello, ID 83201-3314 |
Second Address | Pocatello, ID 83201-3314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010023189 | REGENCE OF ID (01) | ID |
W0533 | BLUE CROSS (01) | ID |