Healthcare Provider Details

I. General information

NPI: 1689806663
Provider Name (Legal Business Name): STEPHANIE LYSSA HOPE CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE ALYSSA MULLEN CST

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 N CURTIS RD SUITE 300
BOISE ID
83706-1300
US

IV. Provider business mailing address

8950 W EMERALD ST STE 168
BOISE ID
83704-8296
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-2600
  • Fax: 208-323-9172
Mailing address:
  • Phone: 208-321-1209
  • Fax: 208-321-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number109240
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: