Provider Demographics
NPI:1679390421
Name:KERN, NANCY (LMT, MLD-C)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:KERN
Suffix:
Gender:F
Credentials:LMT, MLD-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MAIN ST # 361
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4219
Mailing Address - Country:US
Mailing Address - Phone:208-768-7376
Mailing Address - Fax:
Practice Address - Street 1:102 COURTHOUSE DR STE F
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-3905
Practice Address - Country:US
Practice Address - Phone:208-768-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-5422225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist