Healthcare Provider Details

I. General information

NPI: 1558817981
Provider Name (Legal Business Name): KIMBERLY CORDERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 E RIVERSIDE DR STE 120
EAGLE ID
83616-6585
US

IV. Provider business mailing address

13213 N DECHAMBEAU WAY
BOISE ID
83714-9429
US

V. Phone/Fax

Practice location:
  • Phone: 208-906-3644
  • Fax:
Mailing address:
  • Phone: 208-906-3644
  • Fax: 208-493-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-28608
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: