Provider Demographics
NPI:1891023172
Name:DVORAK, CARMEN IGNACIA (RN, CDE)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:IGNACIA
Last Name:DVORAK
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5599 N COLLISTER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1226 W RIVER ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7049
Practice Address - Country:US
Practice Address - Phone:208-331-1155
Practice Address - Fax:208-383-0190
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN38102163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator