Healthcare Provider Details

I. General information

NPI: 1154489110
Provider Name (Legal Business Name): KELLI J GOOLD CFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6140 CURTISIAN AVE STE 400
BOISE ID
83704-8880
US

IV. Provider business mailing address

6140 W CURTISIAN AVE STE 400
BOISE ID
83704-8907
US

V. Phone/Fax

Practice location:
  • Phone: 208-327-5600
  • Fax: 208-327-5602
Mailing address:
  • Phone: 208-327-5600
  • Fax: 208-327-5602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number97822
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: