Provider Demographics
NPI:1063230449
Name:TRANSFORMED MIND AND BODY LLC
Entity type:Organization
Organization Name:TRANSFORMED MIND AND BODY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JONIRUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIGAUM
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:407-865-0101
Mailing Address - Street 1:8040 S RED CLIFF AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3466
Mailing Address - Country:US
Mailing Address - Phone:407-865-0101
Mailing Address - Fax:
Practice Address - Street 1:824 17TH AVE S STE 15
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4780
Practice Address - Country:US
Practice Address - Phone:407-865-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty