Healthcare Provider Details

I. General information

NPI: 1609504356
Provider Name (Legal Business Name): KASEY L WARD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1597
US

IV. Provider business mailing address

164 S 5TH ST
MONTPELIER ID
83254-1597
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1630
  • Fax:
Mailing address:
  • Phone: 208-847-1630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number72880
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: