Healthcare Provider Details

I. General information

NPI: 1538908595
Provider Name (Legal Business Name): SOPHIA ELIZABETH RAABE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 PERIMETER DR
MOSCOW ID
83844-9803
US

IV. Provider business mailing address

18675 NW IDANHA ST
PORTLAND OR
97229-2033
US

V. Phone/Fax

Practice location:
  • Phone: 208-885-6111
  • Fax:
Mailing address:
  • Phone: 971-303-5306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: