Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1083117402 |
---|---|
Provider Name | Tammy Jo Dayley |
First Address | Gooding, ID 83330-5500 |
Second Address | Gooding, ID 83330-5500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/03/2018 |
Last Update Date | 12/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1370131 | MEDICARE PART B (01) | ID |