Healthcare Provider Details

I. General information

NPI: 1679368658
Provider Name (Legal Business Name): JAMIE BUMGARDNER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 E CORPORATE DR STE 200
MERIDIAN ID
83642-2953
US

IV. Provider business mailing address

945 E HEARTHSTONE DR
BOISE ID
83702-1827
US

V. Phone/Fax

Practice location:
  • Phone: 208-283-7314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6471067
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: