Healthcare Provider Details

I. General information

NPI: 1487140265
Provider Name (Legal Business Name): MATUSHKA OLGA MICHAEL MATERNITY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 18TH AVE S
NAMPA ID
83651-4841
US

IV. Provider business mailing address

919 13TH AVE S
NAMPA ID
83651-4618
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-2700
  • Fax: 208-639-2736
Mailing address:
  • Phone: 712-828-0234
  • Fax: 208-965-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCNM81-A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLIE NORTHAM
Title or Position: CEO
Credential: CNM
Phone: 712-828-0234