Healthcare Provider Details

I. General information

NPI: 1164318549
Provider Name (Legal Business Name): DESIRE MICHELLE STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD ST
BOISE ID
83704-8969
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5150
  • Fax: 205-302-5155
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number58334
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number202007769RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number515734
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2371282
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: