Healthcare Provider Details

I. General information

NPI: 1265905772
Provider Name (Legal Business Name): NICOLE VADNAIS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 CURLEW DR
AMMON ID
83406-4718
US

IV. Provider business mailing address

PO BOX 2106
IDAHO FALLS ID
83403-2106
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-5319
  • Fax:
Mailing address:
  • Phone: 208-523-5319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10045
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: