Healthcare Provider Details

I. General information

NPI: 1831044544
Provider Name (Legal Business Name): TIFFANY LEEANNA CUDMORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2026
Last Update Date: 02/27/2026
Certification Date: 02/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 COLORADO AVE
CALDWELL ID
83605-6145
US

IV. Provider business mailing address

3317 COLORADO AVE
CALDWELL ID
83605-6145
US

V. Phone/Fax

Practice location:
  • Phone: 208-219-2081
  • Fax:
Mailing address:
  • Phone: 208-219-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberAB150728J
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: