Healthcare Provider Details

I. General information

NPI: 1194678607
Provider Name (Legal Business Name): KATHERINE GAIL BURACCHIO APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N HIGHBROOK WAY STE 106 PMB 510
STAR ID
83669-1028
US

IV. Provider business mailing address

200 N HIGHBROOK WAY STE 106 PMB 510
STAR ID
83669-1028
US

V. Phone/Fax

Practice location:
  • Phone: 208-418-9335
  • Fax:
Mailing address:
  • Phone: 208-418-9335
  • Fax: 208-978-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2471290
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: