Healthcare Provider Details

I. General information

NPI: 1912956806
Provider Name (Legal Business Name): RALENE WIBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 16TH AVE N
NAMPA ID
83687-4058
US

IV. Provider business mailing address

211 16TH AVE N PO BOX 9
NAMPA ID
83687-4058
US

V. Phone/Fax

Practice location:
  • Phone: 208-461-7149
  • Fax: 208-467-3391
Mailing address:
  • Phone: 208-461-7149
  • Fax: 208-467-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberNP464A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101252362
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-12117
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: