Healthcare Provider Details

I. General information

NPI: 1447032594
Provider Name (Legal Business Name): ILLUMINATION WOMEN'S HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4477 W EMERALD ST STE C200
BOISE ID
83706-2074
US

IV. Provider business mailing address

4477 W EMERALD ST STE C200
BOISE ID
83706-2074
US

V. Phone/Fax

Practice location:
  • Phone: 208-780-9295
  • Fax: 855-490-9559
Mailing address:
  • Phone: 208-780-9295
  • Fax: 855-490-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. KANDISS INMAN
Title or Position: NURSE PRACTITIONER/OWNER
Credential: WHNP-BC, MSN, NCMP
Phone: 208-780-9295