Provider Demographics
NPI:1871042556
Name:DETTORI, NANCY (RN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:DETTORI
Suffix:
Gender:F
Credentials:RN
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 215
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ID
Mailing Address - Zip Code:83327-0215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-0100
Practice Address - Country:US
Practice Address - Phone:208-727-8356
Practice Address - Fax:208-727-8357
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-16655163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator