Healthcare Provider Details

I. General information

NPI: 1033743687
Provider Name (Legal Business Name): VANESSA SUE WARDEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2020
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6848 N GOVERNMENT WAY STE 111
DALTON GARDENS ID
83815-7778
US

IV. Provider business mailing address

14435 N TREEHOUSE CT
RATHDRUM ID
83858-8576
US

V. Phone/Fax

Practice location:
  • Phone: 208-252-6362
  • Fax:
Mailing address:
  • Phone: 208-696-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMASG-2019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: