Healthcare Provider Details

I. General information

NPI: 1598419657
Provider Name (Legal Business Name): MADISON WEATHERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 11TH AVE S STE 155
NAMPA ID
83651-3946
US

IV. Provider business mailing address

101 11TH AVE S STE 155
NAMPA ID
83651-3946
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-1077
  • Fax: 208-467-2201
Mailing address:
  • Phone: 208-466-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number3281922
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: