Healthcare Provider Details

I. General information

NPI: 1477750032
Provider Name (Legal Business Name): WOMEN'S HEALTHCARE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2327 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

2327 CORONADO ST
IDAHO FALLS ID
83404-7407
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2900
  • Fax: 208-557-4973
Mailing address:
  • Phone: 208-557-2981
  • Fax: 208-557-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA410
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP607A
License Number StateID

VIII. Authorized Official

Name: MRS. SANDRA E GNEITING
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 208-557-2910