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General NPI Number Information
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NPI Number | 1043795768
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Entity Type | Individual
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Provider Name | MS. DAWNA MARIE HENDERSON
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Gender | Female
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Dates
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Enumeration Date | 09/27/2018
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Last Update Date | 09/27/2018
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Provider Practice Location Address
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Address Line | 3111 CHANNING WAY
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7534
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Country | US
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Telephone | 208-529-0067
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Fax |
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Provider Business Mailing Address
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Address Line | 957 HOOPES AVE APT 204
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City | IDAHO FALLS
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State | ID
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Zip | 83404-4709
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Country | US
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Telephone | 307-220-8919
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 1986
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License Number State | ID
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