Healthcare Provider Details

I. General information

NPI: 1609362318
Provider Name (Legal Business Name): JUANITA G LAYNE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 ARLINGTON AVE
CALDWELL ID
83605
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-459-1025
  • Fax: 208-459-1080
Mailing address:
  • Phone: 208-461-7149
  • Fax: 208-467-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number59039
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: