Healthcare Provider Details

I. General information

NPI: 1891707360
Provider Name (Legal Business Name): REGENIA L. WILSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 STATE ST
MCCALL ID
83638-3704
US

IV. Provider business mailing address

4283 N NINES RIDGE LN
BOISE ID
83702-1866
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2221
  • Fax: 208-634-7112
Mailing address:
  • Phone: 208-345-5830
  • Fax: 208-345-5830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA109
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: