Healthcare Provider Details

I. General information

NPI: 1467964064
Provider Name (Legal Business Name): SHANNA RENEE DEWEY DOULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2017
Last Update Date: 11/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8274 BIRMINGHAM RD
MELBA ID
83641-4210
US

IV. Provider business mailing address

8274 BIRMINGHAM RD
MELBA ID
83641-4210
US

V. Phone/Fax

Practice location:
  • Phone: 208-896-5889
  • Fax:
Mailing address:
  • Phone: 208-896-5889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: