Healthcare Provider Details

I. General information

NPI: 1316314693
Provider Name (Legal Business Name): VIDA VRECA-PONNEQUIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 1ST ST S
NAMPA ID
83651-3703
US

IV. Provider business mailing address

PO BOX 9
NAMPA ID
83653-0009
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7869
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-467-4431
  • Fax: 208-466-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002571
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64975
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: