Healthcare Provider Details

I. General information

NPI: 1093306169
Provider Name (Legal Business Name): MAKENA LORYN KELLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKENA TURNER

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9951 W ST LUKES DR
NAMPA ID
83687-7914
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-6700
  • Fax: 208-463-6044
Mailing address:
  • Phone: 208-381-8866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: