Healthcare Provider Details

I. General information

NPI: 1821003708
Provider Name (Legal Business Name): AMMARA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30410 HIGHWAY 200
PONDERAY ID
83852-9601
US

IV. Provider business mailing address

30410 HIGHWAY 200
PONDERAY ID
83852-9601
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1345
  • Fax: 208-255-5531
Mailing address:
  • Phone: 208-263-1345
  • Fax: 208-255-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-257A
License Number StateID

VIII. Authorized Official

Name: KATHY GAVIN
Title or Position: OWNER
Credential: FNP
Phone: 208-263-1345