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General NPI Number Information
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NPI Number | 1174105431
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Entity Type | Organization
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Legal Business Name | FRESH AESTHETICS MEDICAL SPA
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Dates
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Enumeration Date | 04/26/2021
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Last Update Date | 04/26/2021
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Provider Practice Location Address
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Address Line | 1411 FALLS AVE E STE 105
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City | TWIN FALLS
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State | ID
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Zip | 83301-3455
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Country | US
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Telephone | 208-358-3637
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Fax |
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Provider Business Mailing Address
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Address Line | 1411 FALLS AVE E STE 105
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City | TWIN FALLS
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State | ID
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Zip | 83301-3455
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Country | US
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Telephone | 208-358-3637
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Fax |
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Authorized Official
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Title or Position | OWNER/NP-C
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Name | ANGELA STANGER
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Credential | AGPCNP
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Telephone | 208-358-3637
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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