Provider Demographics
NPI:1144202938
Name:MUSSMANN, DAVEE CARPENTER (DPT)
Entity Type:Individual
Prefix:MRS
First Name:DAVEE
Middle Name:CARPENTER
Last Name:MUSSMANN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 N 4500 E
Mailing Address - Street 2:
Mailing Address - City:MURTAUGH
Mailing Address - State:ID
Mailing Address - Zip Code:83344-5014
Mailing Address - Country:US
Mailing Address - Phone:208-432-5644
Mailing Address - Fax:
Practice Address - Street 1:1224 8TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1527
Practice Address - Country:US
Practice Address - Phone:208-436-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID633225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010021994OtherBLUE SHIELD
IDT4108OtherBLUE CROSS
ID1650983Medicare ID - Type Unspecified