Healthcare Provider Details

I. General information

NPI: 1699617266
Provider Name (Legal Business Name): KELSEY MOREY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 S WOODDALE AVE
EAGLE ID
83616-7714
US

IV. Provider business mailing address

219 S WOODDALE AVE
EAGLE ID
83616-7714
US

V. Phone/Fax

Practice location:
  • Phone: 208-994-5575
  • Fax:
Mailing address:
  • Phone: 208-994-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6581203
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: