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General NPI Number Information
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NPI Number | 1154402220
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Entity Type | Individual
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Provider Name | MS. GLENDA KAY MOE
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Gender | Female
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Dates
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Enumeration Date | 10/17/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 510 E 17TH S. 400
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-589-0807
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Fax | 208-542-9577
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Provider Business Mailing Address
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Address Line | 185 W WOODHAVEN LN
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8429
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Country | US
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Telephone | 208-569-1882
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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 | OTA204
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License Number State | ID
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