Healthcare Provider Details

I. General information

NPI: 1891182911
Provider Name (Legal Business Name): TIANA JESPERSEN NIZAMIC MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 375
COEUR D ALENE ID
83814-4401
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6100
  • Fax: 208-625-6101
Mailing address:
  • Phone: 208-625-6100
  • Fax: 208-625-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberM-15908
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: