Healthcare Provider Details

I. General information

NPI: 1922641968
Provider Name (Legal Business Name): ANNA BLONQUIST NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 E 25TH ST
IDAHO FALLS ID
83404-7542
US

IV. Provider business mailing address

PO BOX 742358
ATLANTA GA
30374-2358
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-2100
  • Fax: 208-227-2362
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number25763
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: