Healthcare Provider Details

I. General information

NPI: 1477088201
Provider Name (Legal Business Name): KEELY CARDWELL DNAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2017
Last Update Date: 10/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 E BANNOCK ST
BOISE ID
83712-6207
US

IV. Provider business mailing address

781 N SHADOWRIDGE AVE
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-336-0895
  • Fax:
Mailing address:
  • Phone: 816-529-2518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number40228
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number14-126679-032
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number55952
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: