Healthcare Provider Details

I. General information

NPI: 1215621859
Provider Name (Legal Business Name): MICHELLE OVERBY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

1711 S COLORADO AVE
BOISE ID
83706-3839
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax:
Mailing address:
  • Phone: 702-343-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number51022
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: