Provider Demographics
NPI:1881459543
Name:FERNLEY, REAGAN E (PTA)
Entity type:Individual
Prefix:
First Name:REAGAN
Middle Name:E
Last Name:FERNLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 S BENEWAH ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2868
Mailing Address - Country:US
Mailing Address - Phone:651-788-0664
Mailing Address - Fax:
Practice Address - Street 1:134 E IDAHO AVE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628-5003
Practice Address - Country:US
Practice Address - Phone:208-337-3254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID85542081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine