Healthcare Provider Details

I. General information

NPI: 1821788803
Provider Name (Legal Business Name): KATHERINE ANNE WARDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 E FRANKLIN RD STE 201
MERIDIAN ID
83642-2376
US

IV. Provider business mailing address

680 S CALHOUN PL UNIT I301
STAR ID
83669-6235
US

V. Phone/Fax

Practice location:
  • Phone: 208-807-2877
  • Fax:
Mailing address:
  • Phone: 541-554-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1171663
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: