Healthcare Provider Details

I. General information

NPI: 1679782460
Provider Name (Legal Business Name): NICOLE L THURSTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST
BOISE ID
83712-6267
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-2711
  • Fax: 208-323-9604
Mailing address:
  • Phone: 208-381-2222
  • Fax: 208-323-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM10117
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: