Individual
DIANE RAE NIELSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA C
Contact information
Practice address
3430 WASHINGTON PARKWAY, IDAHO FALLS, ID 83404
(208) 523-3060
(208) 523-0028
Mailing address
3430 WASHINGTON PARKWAY, IDAHO FALLS, ID 83404
(208) 523-3060
(208) 523-0028
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
PA178
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010016257
BLUE SHIELD
ID
05
—
004378700
—
ID
01
—
PAKY2
BLUE CROSS
ID
Enumeration date
08/19/2006
Last updated
09/10/2009
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