1730925751 NPI number — RENEE MOTTOH DNP-FNP-C

Table of content: RENEE MOTTOH DNP-FNP-C (NPI 1730925751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730925751 NPI number — RENEE MOTTOH DNP-FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOTTOH
Provider First Name:
RENEE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP-FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730925751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1113 E HORSEHAVEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83854-6014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1621 N 3RD ST STE 850
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-992-4184
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  69217 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 6961760 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6961760 . This is a "DEPARTMENT OF OCCUPATIONAL AND PROFESSIONAL LICENSES" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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