Healthcare Provider Details

I. General information

NPI: 1700616190
Provider Name (Legal Business Name): CDA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6299 W ALLIANCE ST
RATHDRUM ID
83858-0139
US

IV. Provider business mailing address

6299 W ALLIANCE ST
RATHDRUM ID
83858-0139
US

V. Phone/Fax

Practice location:
  • Phone: 208-518-8111
  • Fax: 208-599-9787
Mailing address:
  • Phone: 208-518-8111
  • Fax: 208-599-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIUSKA ALEXANDRA VESTMAN
Title or Position: OWNER
Credential: PMHNP
Phone: 208-518-8111