Healthcare Provider Details

I. General information

NPI: 1477417905
Provider Name (Legal Business Name): SHANDY LUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 W CENTER ST STE L208
POCATELLO ID
83204-4205
US

IV. Provider business mailing address

845 W CENTER ST STE L208
POCATELLO ID
83204-4205
US

V. Phone/Fax

Practice location:
  • Phone: 208-829-3160
  • Fax: 208-242-2302
Mailing address:
  • Phone: 208-829-3160
  • Fax: 208-242-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: