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General NPI Number Information
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NPI Number | 1013594092
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Entity Type | Individual
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Provider Name | EVITA KVISTA
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Gender | Female
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Dates
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Enumeration Date | 03/25/2021
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Last Update Date | 03/25/2021
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Provider Practice Location Address
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Address Line | 225 S LINDER RD APT B301
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City | EAGLE
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State | ID
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Zip | 83616-4426
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Country | US
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Telephone | 208-412-9622
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Fax |
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Provider Business Mailing Address
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Address Line | 225 S LINDER RD APT B301
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City | EAGLE
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State | ID
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Zip | 83616-4426
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Country | US
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Telephone | 208-412-9622
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 65119
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License Number State | ID
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