Healthcare Provider Details

I. General information

NPI: 1982206439
Provider Name (Legal Business Name): JANIE SOUTHERN CRT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 E PLAZA LOOP
NAMPA ID
83687-4931
US

IV. Provider business mailing address

1616 E PLAZA LOOP
NAMPA ID
83687-4931
US

V. Phone/Fax

Practice location:
  • Phone: 208-287-1733
  • Fax: 208-287-1734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License NumberLRT-1366
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: