Healthcare Provider Details

I. General information

NPI: 1487402467
Provider Name (Legal Business Name): TAMARA K NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/07/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W COMMERCE DR, HAYDEN, ID
HAYDEN ID
83835
US

IV. Provider business mailing address

181 W COMMERCE DR, HAYDEN, ID
HAYDEN ID
83835
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-5237
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: