=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942744834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLIN C HORNICK PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2016
-----------------------------------------------------
Last Update Date | 07/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7550 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-375-0666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1422 S GOURLEY ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83705-6041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-610-4864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT4451
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------