Healthcare Provider Details

I. General information

NPI: 1396261129
Provider Name (Legal Business Name): JILL ANN KONRAD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10255 W OVERLAND RD
BOISE ID
83709-1430
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5600
  • Fax: 208-302-5655
Mailing address:
  • Phone: 208-302-5600
  • Fax: 208-302-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56459
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: