Healthcare Provider Details

I. General information

NPI: 1902024888
Provider Name (Legal Business Name): LIZABETH R HUTCHINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 REDMAN ST
CHUBBUCK ID
83202-2673
US

IV. Provider business mailing address

763 REDMAN ST
CHUBBUCK ID
83202-2673
US

V. Phone/Fax

Practice location:
  • Phone: 208-705-0962
  • Fax:
Mailing address:
  • Phone: 208-705-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171M00000X
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: