Healthcare Provider Details

I. General information

NPI: 1275794851
Provider Name (Legal Business Name): NICHOLE ANN JEPPESEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MADISON PROFESSIONAL PARK
REXBURG ID
83440-2058
US

IV. Provider business mailing address

10 MADISON PROFESSIONAL PARK
REXBURG ID
83440-2058
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-9467
  • Fax: 208-656-9466
Mailing address:
  • Phone: 208-656-9467
  • Fax: 208-656-9467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-865
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-865A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: