Healthcare Provider Details

I. General information

NPI: 1477994994
Provider Name (Legal Business Name): CASSI E SHELLY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 E PARKCENTER BLVD # 1051
BOISE ID
83706-6721
US

IV. Provider business mailing address

967 E PARKCENTER BLVD # 1051
BOISE ID
83706-6721
US

V. Phone/Fax

Practice location:
  • Phone: 208-720-9670
  • Fax:
Mailing address:
  • Phone: 208-720-9670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1332A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP123PEND
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: