Healthcare Provider Details

I. General information

NPI: 1477490936
Provider Name (Legal Business Name): RYLIE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 TANGLEWOOD DR
REXBURG ID
83440-4915
US

IV. Provider business mailing address

600 TANGLEWOOD DR
REXBURG ID
83440-4915
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-9946
  • Fax:
Mailing address:
  • Phone: 208-313-9946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: