Healthcare Provider Details

I. General information

NPI: 1811807423
Provider Name (Legal Business Name): MILLIE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 E 17TH ST
IDAHO FALLS ID
83404-6126
US

IV. Provider business mailing address

6325 N SILVER FOX RD APT 1
AMMON ID
83401-6926
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-0688
  • Fax:
Mailing address:
  • Phone: 208-477-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6981221
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: