Healthcare Provider Details

I. General information

NPI: 1336408632
Provider Name (Legal Business Name): LITTLE ANGELS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 WOODRUFF PARK
IDAHO FALLS ID
83401-3330
US

IV. Provider business mailing address

1680 WOODRUFF PARK
IDAHO FALLS ID
83401-3330
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-0711
  • Fax:
Mailing address:
  • Phone: 208-313-0711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-334
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-9188
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LISA RENEA CRUZ
Title or Position: OWNER
Credential: RN
Phone: 208-313-0711