Healthcare Provider Details

I. General information

NPI: 1447455217
Provider Name (Legal Business Name): ANNE MARIE OMALLEY-NEUHAUS N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE MARIE OMALLEY N.P.

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 EAST HOWARD AVENUE TETON VALLEY HEALTH CARE
DRIGGS ID
83422-5112
US

IV. Provider business mailing address

120 EAST HOWARD AVENUE TETON VALLEY HEALTH CARE
DRIGGS ID
83422-5112
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-6302
  • Fax: 208-354-3158
Mailing address:
  • Phone: 208-354-6302
  • Fax: 208-354-3158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0000374
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberNP-927A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: