Healthcare Provider Details

I. General information

NPI: 1275836157
Provider Name (Legal Business Name): DEBRA LYNN RODRIGUEZ CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2010
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY
POCATELLO ID
83201-5162
US

IV. Provider business mailing address

541 S 10TH AVE
POCATELLO ID
83201-4856
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-1000
  • Fax:
Mailing address:
  • Phone: 208-251-1262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS 49A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: