Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 1193 | ID |
NPI | 1003023334 |
---|---|
Provider Name | Mrs. Dianne Denise Nelson |
First Address | Boise, ID 83713-1202 |
Second Address | Boise, ID 83704-8700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2007 |
Last Update Date | 08/07/2007 |