Healthcare Provider Details

I. General information

NPI: 1437008836
Provider Name (Legal Business Name): KENDALL ANN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date: 02/10/2026
Reactivation Date: 05/28/2026

III. Provider practice location address

2117 NAY DR
NAMPA ID
83686-7965
US

IV. Provider business mailing address

2117 NAY DR
NAMPA ID
83686-7965
US

V. Phone/Fax

Practice location:
  • Phone: 208-995-0914
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: