Healthcare Provider Details

I. General information

NPI: 1912486176
Provider Name (Legal Business Name): VICTORIA ALLISON KENT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 AVIATION DR STE 100
HAILEY ID
83333-8785
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-788-3434
  • Fax:
Mailing address:
  • Phone: 208-381-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMRO-1829
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-1430
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: