Provider Demographics
NPI:1376771667
Name:PRISSEL, JUANITA E (MD)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:E
Last Name:PRISSEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:E
Other - Last Name:SWENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:120 E HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6302
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:120 E HOWARD ST
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-6302
Practice Address - Fax:208-354-3158
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11239207Q00000X
MT19217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine