Healthcare Provider Details

I. General information

NPI: 1629428362
Provider Name (Legal Business Name): TERESA YORK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 BEAVERSLIDE RD
KAMIAH ID
83536-5113
US

IV. Provider business mailing address

169 BEAVERSLIDE RD
KAMIAH ID
83536
US

V. Phone/Fax

Practice location:
  • Phone: 208-935-7963
  • Fax:
Mailing address:
  • Phone: 208-935-7963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberW143727
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: