Healthcare Provider Details

I. General information

NPI: 1457296865
Provider Name (Legal Business Name): MRS. RONDA MARIE CODY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 DORTHA ST
BLACKFOOT ID
83221-1902
US

IV. Provider business mailing address

73 DORTHA ST
BLACKFOOT ID
83221-1902
US

V. Phone/Fax

Practice location:
  • Phone: 208-240-1135
  • Fax:
Mailing address:
  • Phone: 208-240-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: