Healthcare Provider Details

I. General information

NPI: 1639004583
Provider Name (Legal Business Name): MARCELA AZEVEDO PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 COTTONWOOD CT
EAGLE ID
83616-6577
US

IV. Provider business mailing address

45 COTTONWOOD CT STE 140
EAGLE ID
83616-6577
US

V. Phone/Fax

Practice location:
  • Phone: 208-648-4100
  • Fax:
Mailing address:
  • Phone: 208-648-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9681016
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: