Healthcare Provider Details

I. General information

NPI: 1386987055
Provider Name (Legal Business Name): KATHERINE WINGATE QUAYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 AVIATION DR STE 202
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: 208-727-8970
  • Fax: 208-727-8979
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9148249-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number57.252141
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberM-14263
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: