Healthcare Provider Details

I. General information

NPI: 1871639112
Provider Name (Legal Business Name): MRS. MELINDA LOU MULKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22568 HOSKINS RD
WILDER ID
83676-5828
US

IV. Provider business mailing address

22568 HOSKINS RD
WILDER ID
83676
US

V. Phone/Fax

Practice location:
  • Phone: 208-337-4763
  • Fax:
Mailing address:
  • Phone: 208-337-4763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number30218
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: