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General NPI Number Information
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NPI Number | 1114342755
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Entity Type | Organization
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Legal Business Name | LULLABY WATERS PLLC
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Dates
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Enumeration Date | 02/19/2014
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Last Update Date | 07/13/2021
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Provider Practice Location Address
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Address Line | 1410 S BROADWAY AVE
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City | BOISE
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State | ID
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Zip | 83706-3706
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Country | US
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Telephone | 208-949-3481
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Fax |
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Provider Business Mailing Address
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Address Line | 179 E OLD SAYBROOK DR
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City | BOISE
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State | ID
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Zip | 83706-4918
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE NICKELL
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Credential |
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Telephone | 208-949-3481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-1014
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License Number State | ID
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