Healthcare Provider Details

I. General information

NPI: 1114755527
Provider Name (Legal Business Name): EMMA ELYSE HULL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W BURNSIDE AVE STE B
POCATELLO ID
83202-4703
US

IV. Provider business mailing address

94 YALE ST
POCATELLO ID
83201-3436
US

V. Phone/Fax

Practice location:
  • Phone: 208-904-1112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberTSLP-5914
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: