Healthcare Provider Details

I. General information

NPI: 1083069488
Provider Name (Legal Business Name): MAKENZI GWINN AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY STE 115
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

777 HOSPITAL WAY STE 115
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1960
  • Fax: 208-478-0076
Mailing address:
  • Phone: 208-239-1960
  • Fax: 208-478-0076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: