MEDICARE: MERJURIE FAIR RICKLEFS ARNP, PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	66558	ID

General Provider Information

NPI Number	:	1821693094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERJURIE FAIR RICKLEFS ARNP, PMHNP-BC

Provider Business Mailing Address
First Line	:	3670 S 25TH E STE 4
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4956
Country	:	US
Telephone Number	:	208-821-0357
Fax Number	:

Provider Business Practice Location Address
First Line	:	3670 S 25TH E STE 4
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4956
Country	:	US
Telephone Number	:	208-821-0357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2020
Last Update Date	:	04/14/2021

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