Healthcare Provider Details

I. General information

NPI: 1912948464
Provider Name (Legal Business Name): MARYBETH PUZIO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

2537 W STATE ST STE 200
BOISE ID
83702-2200
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2222
  • Fax:
Mailing address:
  • Phone: 208-336-0895
  • Fax: 208-338-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberN24138
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA341
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: