Healthcare Provider Details

I. General information

NPI: 1629329537
Provider Name (Legal Business Name): STEPHANIE MARGARET CARPENTER PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE MARGARET RENNE

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 8TH ST
LEWISTON ID
83501-7303
US

IV. Provider business mailing address

2315 8TH ST
LEWISTON ID
83501-7303
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-1383
  • Fax: 208-746-6348
Mailing address:
  • Phone: 208-746-1383
  • Fax: 208-746-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP-1229A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60511737
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1229A
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60511737
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: