Provider Demographics
NPI:1215739685
Name:PABAWENA, ASHLYNN IRENE
Entity type:Individual
Prefix:
First Name:ASHLYNN
Middle Name:IRENE
Last Name:PABAWENA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N COLE RD APT D102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7373
Mailing Address - Country:US
Mailing Address - Phone:208-519-6481
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD SUITE 100, BOISE, ID 83712
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-369-9168
Practice Address - Fax:800-513-7773
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty