Healthcare Provider Details

I. General information

NPI: 1629835962
Provider Name (Legal Business Name): NICOLE M. HUTTASH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 S HILLSDALE AVE
MERIDIAN ID
83642-7586
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-6457
  • Fax: 208-706-6411
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78713
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: