Healthcare Provider Details

I. General information

NPI: 1215562509
Provider Name (Legal Business Name): NICOLE MARIE WEISS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 09/23/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S POLK ST
MOSCOW ID
83843-3356
US

IV. Provider business mailing address

411 S POLK ST
MOSCOW ID
83843-3356
US

V. Phone/Fax

Practice location:
  • Phone: 208-310-3261
  • Fax: 208-742-3481
Mailing address:
  • Phone: 208-310-3261
  • Fax: 208-742-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202651
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP61045630
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: