Provider Demographics
NPI:1336706936
Name:NEVINS, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:NEVINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 W CHRISFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3256
Mailing Address - Country:US
Mailing Address - Phone:360-722-9349
Mailing Address - Fax:
Practice Address - Street 1:1625 W STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4003
Practice Address - Country:US
Practice Address - Phone:208-336-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist