Provider Demographics
NPI:1083386155
Name:ECHI-ABOLI, ATITIDA
Entity Type:Individual
Prefix:
First Name:ATITIDA
Middle Name:
Last Name:ECHI-ABOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 E 3RD N
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1525
Mailing Address - Country:US
Mailing Address - Phone:385-515-5386
Mailing Address - Fax:
Practice Address - Street 1:123 E 3RD N
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1525
Practice Address - Country:US
Practice Address - Phone:385-515-5386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide