Healthcare Provider Details

I. General information

NPI: 1336930734
Provider Name (Legal Business Name): KYLE SPENCER CONGER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E LOCUST ST
EMMETT ID
83617-2715
US

IV. Provider business mailing address

11360 W BLUE FOX ST
BOISE ID
83709-6917
US

V. Phone/Fax

Practice location:
  • Phone: 208-901-3287
  • Fax: 208-365-3572
Mailing address:
  • Phone: 801-347-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number51549
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number51549
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: