Healthcare Provider Details

I. General information

NPI: 1487773156
Provider Name (Legal Business Name): SUSAN IWASA RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 W RIVER ST
BOISE ID
83702-7049
US

IV. Provider business mailing address

253 W MAIN ST
WEISER ID
83672-1835
US

V. Phone/Fax

Practice location:
  • Phone: 208-331-1155
  • Fax: 208-383-0190
Mailing address:
  • Phone: 208-884-0048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberN-15513
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: