Healthcare Provider Details

I. General information

NPI: 1871832881
Provider Name (Legal Business Name): VIENNA GRAYCE KATANA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 01/10/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4664 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7442
US

IV. Provider business mailing address

4664 N PENNGROVE WAY STE 100
MERIDIAN ID
83646-7442
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-7467
  • Fax:
Mailing address:
  • Phone: 208-898-7467
  • Fax: 208-398-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20A13629
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number13629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: