Healthcare Provider Details

I. General information

NPI: 1083578942
Provider Name (Legal Business Name): GEORGINA RAFIELITA MARSHALL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 OLYMPUS DR
POCATELLO ID
83201-2271
US

IV. Provider business mailing address

777 HOSPITAL WAY
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-2273
  • Fax:
Mailing address:
  • Phone: 208-239-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3071395
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: