Healthcare Provider Details

I. General information

NPI: 1205658978
Provider Name (Legal Business Name): SAMANTHA KAITLIN LEGAULT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

6933 W EMERALD ST
BOISE ID
83704-8616
US

IV. Provider business mailing address

7848 W MCMULLEN ST
BOISE ID
83709-0839
US

V. Phone/Fax

Practice location:
  • Phone: 208-321-0634
  • Fax:
Mailing address:
  • Phone: 208-353-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8861276
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: