Healthcare Provider Details

I. General information

NPI: 1376084673
Provider Name (Legal Business Name): MARCI AHLQUIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCI DATE APRN-CNP

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 POLE LINE RD W SUITE 203
TWIN FALLS ID
83301-5814
US

IV. Provider business mailing address

775 POLE LINE ROAD WEST SUITE NUMBER 203
TWIN FALLS ID
83301
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-8300
  • Fax: 208-733-8970
Mailing address:
  • Phone: 208-814-8300
  • Fax: 208-733-8970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55418
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: