Healthcare Provider Details

I. General information

NPI: 1518236785
Provider Name (Legal Business Name): STEPHANIE JOHNSON HUTCHENS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE CANDICE JOHNSON MOONEY FNP-C

II. Dates (important events)

Enumeration Date: 12/17/2011
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-3494
  • Fax:
Mailing address:
  • Phone: 208-381-3494
  • Fax: 208-381-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1341A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number-201150178NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: