Healthcare Provider Details

I. General information

NPI: 1730925751
Provider Name (Legal Business Name): RENEE MOTTOH DNP-FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 N 3RD ST STE 850
COEUR D ALENE ID
83814-3326
US

IV. Provider business mailing address

1113 E HORSEHAVEN AVE
POST FALLS ID
83854-6014
US

V. Phone/Fax

Practice location:
  • Phone: 208-992-4184
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6961760
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number69217
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: