Healthcare Provider Details

I. General information

NPI: 1710197264
Provider Name (Legal Business Name): KELLEEN LOUISE FAKENBRIDGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8324 W NORTHVIEW ST SUITE 100
BOISE ID
83704-7184
US

IV. Provider business mailing address

8324 W NORTHVIEW ST SUITE 101
BOISE ID
83704-7184
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-8337
  • Fax: 208-376-8344
Mailing address:
  • Phone: 208-376-8337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP732
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: