Healthcare Provider Details

I. General information

NPI: 1760558605
Provider Name (Legal Business Name): JACALYN SIEMER CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 3RD AVENUE
SANDPOINT ID
83864
US

IV. Provider business mailing address

192 SUNRISE CIRCLE
SAGLE ID
83860
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1441
  • Fax:
Mailing address:
  • Phone: 208-263-6752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberN-21782
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: