Healthcare Provider Details

I. General information

NPI: 1992520282
Provider Name (Legal Business Name): CARLI MCDONNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

3427 E BOISE AVE
BOISE ID
83706-5741
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-3223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number73325
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: