Healthcare Provider Details

I. General information

NPI: 1952917353
Provider Name (Legal Business Name): WENDE CHRISTINE LEAVITT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

IV. Provider business mailing address

2001 S WOODRUFF AVE STE 9
IDAHO FALLS ID
83404-6371
US

V. Phone/Fax

Practice location:
  • Phone: 208-419-3002
  • Fax: 208-656-5652
Mailing address:
  • Phone: 208-419-3002
  • Fax: 208-656-5652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1938
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberPA-1938
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: