Healthcare Provider Details

I. General information

NPI: 1376647909
Provider Name (Legal Business Name): RAQUEL RENEE KACIN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 10/02/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3167 WEST BELLTOWER DRIVE SUITE 120
MERIDIAN ID
83646
US

IV. Provider business mailing address

1909 E JADE CREEK LN
EAGLE ID
83616-7697
US

V. Phone/Fax

Practice location:
  • Phone: 208-908-7797
  • Fax: 208-908-6588
Mailing address:
  • Phone: 757-934-4661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN000865
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN25040
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77590
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: