Healthcare Provider Details

I. General information

NPI: 1316884091
Provider Name (Legal Business Name): ADAM JOSEPH THETFORD APRN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 LUV PL
AMMON ID
83406-4511
US

IV. Provider business mailing address

315 LUV PL
AMMON ID
83406-4511
US

V. Phone/Fax

Practice location:
  • Phone: 208-821-4357
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5981802
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: