Healthcare Provider Details

I. General information

NPI: 1811759426
Provider Name (Legal Business Name): SAMANTHA J RUGGLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 E LOUISE DR
MERIDIAN ID
83642-6302
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7312
  • Fax: 208-381-7313
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number60433
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: