Healthcare Provider Details

I. General information

NPI: 1790904779
Provider Name (Legal Business Name): KRISTINA NICHOLAS ANDERSON LSW, MASTERS STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5624 N GOVERNMENT WAY SUITE 7B
DALTON GARDENS ID
83815-7350
US

IV. Provider business mailing address

5624 N GOVERNMENT WAY SUITE 7B
DALTON GARDENS ID
83815-7350
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-9890
  • Fax: 208-762-9892
Mailing address:
  • Phone: 208-762-9890
  • Fax: 208-762-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW-2298
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: