Healthcare Provider Details

I. General information

NPI: 1477204634
Provider Name (Legal Business Name): SUZANNE ELISE MONAGHAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

381 S MIDDLETON RD STE B
MIDDLETON ID
83644-5369
US

IV. Provider business mailing address

PO BOX 277976
ATLANTA GA
30384-7976
US

V. Phone/Fax

Practice location:
  • Phone: 208-585-6311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number69911
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: