Healthcare Provider Details

I. General information

NPI: 1669990685
Provider Name (Legal Business Name): STEPHANIE NIELSEN BAKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LEE NIELSEN

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S 7TH ST
ST MARIES ID
83861-1803
US

IV. Provider business mailing address

229 S 7TH ST
ST MARIES ID
83861-1803
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-2591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56789
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: