MEDICARE: RACHEL ELLEN PEAY-GOODMAN FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	56883	ID

General Provider Information

NPI Number	:	1164941803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHEL ELLEN PEAY-GOODMAN FNP-BC

Provider Business Mailing Address
First Line	:	357 LA MONTAGNA STRADA
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-5800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	396 YELLOWSTONE AVE
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-4572
Country	:	US
Telephone Number	:	208-254-7733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2017
Last Update Date	:	01/31/2020

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