Healthcare Provider Details

I. General information

NPI: 1538697610
Provider Name (Legal Business Name): CAITLYN WARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMETER DR
MOSCOW ID
83844-9803
US

IV. Provider business mailing address

PO BOX 129
ATHOL ID
83801-0129
US

V. Phone/Fax

Practice location:
  • Phone: 208-885-2182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number65636
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: