Healthcare Provider Details

I. General information

NPI: 1710163456
Provider Name (Legal Business Name): STACEY CARDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 E BANNOCK ST
BOISE ID
83712-6208
US

IV. Provider business mailing address

341 E BANNOCK ST
BOISE ID
83712-6208
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-8180
  • Fax:
Mailing address:
  • Phone: 208-342-8180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number100543
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: