Provider Demographics
NPI:1770147944
Name:NEBEKER, TRUDY
Entity type:Individual
Prefix:MS
First Name:TRUDY
Middle Name:
Last Name:NEBEKER
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 1:4222 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2037
Mailing Address - Country:US
Mailing Address - Phone:208-605-3663
Mailing Address - Fax:208-605-3663
Practice Address - Street 1:4222 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2037
Practice Address - Country:US
Practice Address - Phone:208-605-3663
Practice Address - Fax:208-605-3663
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1154817021Medicaid