Healthcare Provider Details

I. General information

NPI: 1831442482
Provider Name (Legal Business Name): ASHLEY L BALLENSKY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 MISSION ROAD
FORT HALL ID
83203-0717
US

IV. Provider business mailing address

PO BOX 717
FORT HALL ID
83203-0717
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-5423
  • Fax: 208-238-5465
Mailing address:
  • Phone: 208-238-5423
  • Fax: 208-238-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberN-39540
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: