Healthcare Provider Details

I. General information

NPI: 1053756403
Provider Name (Legal Business Name): MELISSA MARIE PANNELL RN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 E LANARK DR
MERIDIAN ID
83642-5982
US

IV. Provider business mailing address

10482 W CARLTON BAY DR
GARDEN CITY ID
83714-5143
US

V. Phone/Fax

Practice location:
  • Phone: 208-895-8670
  • Fax: 208-955-0494
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1971656
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: