Healthcare Provider Details

I. General information

NPI: 1477094498
Provider Name (Legal Business Name): CAROLINE SASSETTI-HRYCZYK CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S 11TH AVE STE 204
POCATELLO ID
83201-4878
US

IV. Provider business mailing address

500 S 11TH AVE STE 400
POCATELLO ID
83201-4880
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-3355
  • Fax: 855-230-7350
Mailing address:
  • Phone: 208-232-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number73856
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNCO-000006
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: