Provider Demographics
NPI:1790518751
Name:ANDERSON, DANIEL RULON (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RULON
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 BRAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-6887
Mailing Address - Country:US
Mailing Address - Phone:208-960-0559
Mailing Address - Fax:
Practice Address - Street 1:715 BRAMPTON DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-6887
Practice Address - Country:US
Practice Address - Phone:208-960-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13614702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry