Healthcare Provider Details

I. General information

NPI: 1205940962
Provider Name (Legal Business Name): DIANE RAE NIELSEN PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3430 WASHINGTON PARKWAY
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

3430 WASHINGTON PARKWAY
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-3060
  • Fax: 208-523-0028
Mailing address:
  • Phone: 208-523-3060
  • Fax: 208-523-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA178
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: