Healthcare Provider Details

I. General information

NPI: 1104318690
Provider Name (Legal Business Name): JANICE PREUIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 POLE LINE RD W
TWIN FALLS ID
83301
US

IV. Provider business mailing address

2200 SELWAY ST
TWIN FALLS ID
83301-7868
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-3633
  • Fax:
Mailing address:
  • Phone: 208-420-9769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number31630
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number31630
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: