Healthcare Provider Details

I. General information

NPI: 1053650010
Provider Name (Legal Business Name): KELLIE ANN NORTHAM PMHNP-BC, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 18TH AVE S
NAMPA ID
83651-4841
US

IV. Provider business mailing address

116 18TH AVE S
NAMPA ID
83651-4841
US

V. Phone/Fax

Practice location:
  • Phone: 208-639-2700
  • Fax: 208-639-2736
Mailing address:
  • Phone: 208-639-2700
  • Fax: 208-639-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number61450
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM81-A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: