Healthcare Provider Details

I. General information

NPI: 1053166199
Provider Name (Legal Business Name): WILLIE SLY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1672 S WOODSAGE AVE STE 120
MERIDIAN ID
83642-8332
US

IV. Provider business mailing address

1672 S WOODSAGE AVE STE 120
MERIDIAN ID
83642-8332
US

V. Phone/Fax

Practice location:
  • Phone: 208-248-4683
  • Fax:
Mailing address:
  • Phone: 208-248-4683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5971891
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: