Provider Demographics
NPI:1366801458
Name:NOT TSOO GAH NEE
Entity type:Organization
Organization Name:NOT TSOO GAH NEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ALCORN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:208-238-5427
Mailing Address - Street 1:PO BOX 717 MISSION RD
Mailing Address - Street 2:
Mailing Address - City:FT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203
Mailing Address - Country:US
Mailing Address - Phone:208-238-5427
Mailing Address - Fax:
Practice Address - Street 1:717 MISSION RD
Practice Address - Street 2:
Practice Address - City:FT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-238-5427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-15140261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003398900Medicaid