Healthcare Provider Details

I. General information

NPI: 1164759379
Provider Name (Legal Business Name): REBECCA S KIRK-EWING RN CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 LEWISTON ST
COTTONWOOD ID
83522-9750
US

IV. Provider business mailing address

PO BOX 137
COTTONWOOD ID
83522-0137
US

V. Phone/Fax

Practice location:
  • Phone: 208-962-3251
  • Fax: 208-962-2323
Mailing address:
  • Phone: 208-952-3251
  • Fax: 208-962-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number2031-0119
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: