Basic Information
| Provider Information | |||||||||
| NPI: | 1255080321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAHLE | ||||||||
| FirstName: | KAITANA | ||||||||
| MiddleName: | MARTINEZ | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1431 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836615352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086427364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1441 NE 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | PAYETTE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836615420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086429376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.485483 | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | 202204058RN | OR | N | Nursing Service Providers | Registered Nurse | 163W00000X | 72647 | ID | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 202207545NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 72647 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.