Provider Demographics
NPI:1447097456
Name:ROTMAN, IVANNA TALI
Entity type:Individual
Prefix:MRS
First Name:IVANNA
Middle Name:TALI
Last Name:ROTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2832 E RED FIR CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7102
Mailing Address - Country:US
Mailing Address - Phone:208-761-8330
Mailing Address - Fax:
Practice Address - Street 1:1311 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7991
Practice Address - Country:US
Practice Address - Phone:208-282-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-6054231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist