Healthcare Provider Details

I. General information

NPI: 1366882813
Provider Name (Legal Business Name): LISA VANETTE LINDSTROM HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD SUITE 303
BOISE ID
83706-1338
US

IV. Provider business mailing address

901 N CURTIS RD SUITE 303
BOISE ID
83706
US

V. Phone/Fax

Practice location:
  • Phone: 208-629-8862
  • Fax:
Mailing address:
  • Phone: 208-629-8862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-2318
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: