Healthcare Provider Details

I. General information

NPI: 1790917789
Provider Name (Legal Business Name): JULIA LANCASTER MUCKERMAN CNM, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY SUITE 300
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

777 HOSPITAL WAY SUITE 300
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-6100
  • Fax:
Mailing address:
  • Phone: 208-232-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM 54A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: