Healthcare Provider Details

I. General information

NPI: 1720640998
Provider Name (Legal Business Name): MAKENA MUELLER PT, DPT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 S RIVERSHORE LN STE 220
EAGLE ID
83616-5783
US

IV. Provider business mailing address

2717 W BANNOCK ST
BOISE ID
83702-4759
US

V. Phone/Fax

Practice location:
  • Phone: 208-629-1030
  • Fax:
Mailing address:
  • Phone: 719-432-6943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: