Healthcare Provider Details

I. General information

NPI: 1104958214
Provider Name (Legal Business Name): ELLOUISE GEBAUER-ATKINS F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 E 3800 N
BUHL ID
83316-6118
US

IV. Provider business mailing address

1650 E 3800 N
BUHL ID
83316-6118
US

V. Phone/Fax

Practice location:
  • Phone: 208-543-4233
  • Fax:
Mailing address:
  • Phone: 208-543-4233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-47A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: