Healthcare Provider Details

I. General information

NPI: 1255160735
Provider Name (Legal Business Name): KATIE LYNN PICKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 17TH ST
LEWISTON ID
83501-3652
US

IV. Provider business mailing address

PO BOX 1664
LEWISTON ID
83501-1467
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-8416
  • Fax:
Mailing address:
  • Phone: 509-290-3148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6461572
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: