Healthcare Provider Details

I. General information

NPI: 1760872865
Provider Name (Legal Business Name): NYKOL BAILEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E BANNOCK ST
BOISE ID
83712-6241
US

IV. Provider business mailing address

210 N SHIRTTAIL WAY
BLANDING UT
84511-3220
US

V. Phone/Fax

Practice location:
  • Phone: 435-459-4194
  • Fax:
Mailing address:
  • Phone: 435-459-4194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105690
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number70140
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: