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General NPI Number Information
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NPI Number | 1437945391
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Entity Type | Organization
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Legal Business Name | FORTIFY OPTIMAL HEALTH
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Dates
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Enumeration Date | 04/17/2025
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 1189 RED ROBIN AVE
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City | AMMON
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State | ID
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Zip | 83401-5747
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Country | US
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Telephone | 619-602-4520
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Fax |
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Provider Business Mailing Address
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Address Line | 784 SOUTH CLEAR LOOP STE R
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City | POST FALLS
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State | ID
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Zip | 83854
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Country | US
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Telephone | 619-602-4520
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SUSANNAH HANCOCK
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Credential | FNP
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Telephone | 619-602-4520
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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