Healthcare Provider Details

I. General information

NPI: 1750397238
Provider Name (Legal Business Name): CYNTHIA M BOULTON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7272 W POTOMAC DR
BOISE ID
83704-9149
US

IV. Provider business mailing address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-2922
  • Fax: 208-463-3044
Mailing address:
  • Phone: 208-463-3000
  • Fax: 208-463-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4874524-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1122A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: