Healthcare Provider Details

I. General information

NPI: 1619007903
Provider Name (Legal Business Name): MANDY R REDMOND A.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E HOMEDALE RD
CALDWELL ID
83607-1848
US

IV. Provider business mailing address

1572 ISLAND VIEW CT
PAYETTE ID
83661-2000
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-9253
  • Fax:
Mailing address:
  • Phone: 208-642-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: