Healthcare Provider Details

I. General information

NPI: 1982301982
Provider Name (Legal Business Name): ABIGAIL DAWN CRANDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WINN DR STE 100
REXBURG ID
83440-5277
US

IV. Provider business mailing address

1209 N 990 E
SHELLEY ID
83274-5177
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-0174
  • Fax: 208-356-0176
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA8612
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: