Healthcare Provider Details

I. General information

NPI: 1851831200
Provider Name (Legal Business Name): SHANNON BORDES FNP-BC, APRN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6259 W EMERALD ST
BOISE ID
83704-8731
US

IV. Provider business mailing address

1910 UNIVERSITY DR
BOISE ID
83725-0002
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-1900
  • Fax: 208-375-5286
Mailing address:
  • Phone: 208-426-1459
  • Fax: 208-426-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number54945
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54945
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: