Healthcare Provider Details

I. General information

NPI: 1114544541
Provider Name (Legal Business Name): KATELYN M VANDERPOOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 PARKCENTRE WAY STE 7
NAMPA ID
83651-1794
US

IV. Provider business mailing address

1650 S TOPAZ WAY
MERIDIAN ID
83642-4474
US

V. Phone/Fax

Practice location:
  • Phone: 208-229-6050
  • Fax: 855-212-5682
Mailing address:
  • Phone: 208-605-7070
  • Fax: 208-898-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: