Healthcare Provider Details

I. General information

NPI: 1457272700
Provider Name (Legal Business Name): EMMANUEL TOBILOBA FASOOTO DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 S WOODSAGE AVE
MERIDIAN ID
83642-8329
US

IV. Provider business mailing address

1672 S WOODSAGE AVE
MERIDIAN ID
83642-8329
US

V. Phone/Fax

Practice location:
  • Phone: 208-248-4683
  • Fax:
Mailing address:
  • Phone: 208-248-4683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number8381022
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: