Healthcare Provider Details

I. General information

NPI: 1699144253
Provider Name (Legal Business Name): SHANNON HAYES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

500 W FORT ST
BOISE ID
83702-4501
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1435
  • Fax: 208-422-1067
Mailing address:
  • Phone: 208-422-1435
  • Fax: 208-422-1067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number092000437RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: