Healthcare Provider Details

I. General information

NPI: 1003728478
Provider Name (Legal Business Name): SUMMER MANGELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 17TH ST
AMMON ID
83406-6669
US

IV. Provider business mailing address

2705 E 17TH ST
AMMON ID
83406-6669
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: