Healthcare Provider Details

I. General information

NPI: 1922505205
Provider Name (Legal Business Name): KELLY ANNE HEUSINKVELD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10583 W LAKE HAZEL RD
BOISE ID
83709
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5950
  • Fax: 208-302-5955
Mailing address:
  • Phone: 208-302-5950
  • Fax: 208-302-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1652
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: