Healthcare Provider Details

I. General information

NPI: 1720628308
Provider Name (Legal Business Name): JULIETTE ANN HOLLINGSHEAD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

IV. Provider business mailing address

2985 CORTEZ AVE
IDAHO FALLS ID
83404-7554
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-3373
  • Fax: 208-523-8746
Mailing address:
  • Phone: 208-523-3373
  • Fax: 208-523-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number62937
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: