Healthcare Provider Details

I. General information

NPI: 1093718702
Provider Name (Legal Business Name): SHANNON DEE GAERTNER-EWING DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 W GEORGIA AVE STE 120
NAMPA ID
83686-6812
US

IV. Provider business mailing address

PO BOX 3306
NAMPA ID
83653-3306
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-5994
  • Fax: 208-467-5127
Mailing address:
  • Phone: 208-467-5994
  • Fax: 208-467-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCHIA829
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: