Healthcare Provider Details

I. General information

NPI: 1982839387
Provider Name (Legal Business Name): TIA NOWACKI ATC, NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 S HILLSDALE AVE
MERIDIAN ID
83642-7587
US

IV. Provider business mailing address

3001 132ND AVE NW
SPICER MN
56288-9469
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-9710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-494
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberA-3683245
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: