Healthcare Provider Details

I. General information

NPI: 1891423323
Provider Name (Legal Business Name): KELSEY EVANS WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARK BLVD STE 110
BOISE ID
83712-7792
US

IV. Provider business mailing address

2120 W STATE ST
BOISE ID
83702-3843
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-5900
  • Fax:
Mailing address:
  • Phone: 208-863-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number55233
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: