Healthcare Provider Details

I. General information

NPI: 1669938320
Provider Name (Legal Business Name): KELLY RUSSELL MSN,RN,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N LIBERTY ST STE 101
BOISE ID
83704-8858
US

IV. Provider business mailing address

900 N LIBERTY ST STE 101
BOISE ID
83704-8858
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-8787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number79075
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: