Healthcare Provider Details

I. General information

NPI: 1467755769
Provider Name (Legal Business Name): MARY JANE HULSEY FPMH-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 HARRISON ST
TWIN FALLS ID
83301-3925
US

IV. Provider business mailing address

823 HARRISON ST
TWIN FALLS ID
83301-3925
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-2177
  • Fax: 208-736-2113
Mailing address:
  • Phone: 208-736-2177
  • Fax: 208-736-2113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number22215A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: