Basic Information
| Provider Information | |||||||||
| NPI: | 1578055885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRUESDELL | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1710 EMERALD AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082303878 | ||||||||
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| Practice Location | |||||||||
| Address1: | 502 S EAGLE RD | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087065000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2018 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT-772 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 2000038852 | 01 | BOC NUMBER | OTHER | AT-772 | 01 | ID | STATE LICENSURE NUMBER | OTHER |