Provider Demographics
NPI:1609110964
Name:DARDIS, KATHRYN ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ANN
Last Name:DARDIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2789
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-2789
Mailing Address - Country:US
Mailing Address - Phone:208-634-4526
Mailing Address - Fax:
Practice Address - Street 1:418 FLOYDE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-4508
Practice Address - Country:US
Practice Address - Phone:208-634-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-440314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility