Healthcare Provider Details

I. General information

NPI: 1376286732
Provider Name (Legal Business Name): MOMMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
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: 208-807-2867
  • Fax: 208-639-2736
Mailing address:
  • Phone: 208-807-2867
  • Fax: 208-639-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLIE NORTHAM
Title or Position: PRIMARY OPERATOR
Credential: PMHNP,BC
Phone: 712-828-0234