Healthcare Provider Details

I. General information

NPI: 1174164263
Provider Name (Legal Business Name): TAMI ANNE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 S BROADWAY AVE STE 101
BOISE ID
83706-4229
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-1222
  • Fax: 208-345-1261
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number77988
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: