Healthcare Provider Details

I. General information

NPI: 1558564138
Provider Name (Legal Business Name): KIMBERLY SPEARS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1902 JUDITH LN SUITE 110
BOISE ID
83705-5235
US

IV. Provider business mailing address

PO BOX 190601
BOISE ID
83719-0601
US

V. Phone/Fax

Practice location:
  • Phone: 208-658-0800
  • Fax: 208-323-1894
Mailing address:
  • Phone: 208-371-2703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17148A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: