Healthcare Provider Details

I. General information

NPI: 1184879363
Provider Name (Legal Business Name): KATHRYN A WICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN ALICE GRAY NP

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 23RD ST
BOISE ID
83702-9100
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-3512
  • Fax: 208-344-4898
Mailing address:
  • Phone: 208-461-7149
  • Fax: 208-467-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP-907A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-907A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: