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General NPI Number Information
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NPI Number | 1871311647
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY AND ALLERGIES CLINIC AT TETON VALLEY PLLC
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Dates
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Enumeration Date | 10/01/2024
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 40 E LITTLE AVE
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City | DRIGGS
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State | ID
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Zip | 83422-5138
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Country | US
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Telephone | 208-354-8220
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 967
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City | VICTOR
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State | ID
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Zip | 83455-0967
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Country | US
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Telephone | 813-230-4241
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | LYUDMYLA NORGART
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Credential | ARNP
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Telephone | 813-230-4241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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