Healthcare Provider Details

I. General information

NPI: 1073675617
Provider Name (Legal Business Name): LEONA JO'ANNE' CHURCH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 W FAIRVIEW AVE STE 206
BOISE ID
83702-5190
US

IV. Provider business mailing address

1655 W FAIRVIEW AVE STE 206
BOISE ID
83702-5190
US

V. Phone/Fax

Practice location:
  • Phone: 208-395-0000
  • Fax: 208-395-0009
Mailing address:
  • Phone: 208-395-0000
  • Fax: 208-395-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNP-157A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: