Healthcare Provider Details

I. General information

NPI: 1962378927
Provider Name (Legal Business Name): ALYSHA LYNN LAXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 10/24/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N 7TH AVE
POCATELLO ID
83201-5756
US

IV. Provider business mailing address

325 N 7TH AVE
POCATELLO ID
83201-5756
US

V. Phone/Fax

Practice location:
  • Phone: 208-226-0065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: