Healthcare Provider Details

I. General information

NPI: 1467762856
Provider Name (Legal Business Name): JENIFER SHANON CONN APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 12TH AVENUE RD STE 200
NAMPA ID
83686
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-0600
  • Fax: 208-302-0755
Mailing address:
  • Phone: 208-302-0600
  • Fax: 208-302-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number60035
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberN32302
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: