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General NPI Number Information
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NPI Number | 1023821196
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Entity Type | Individual
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Provider Name | CRYSTAL LEIGH ROSE FNP-C
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Gender | Female
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Dates
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Enumeration Date | 01/30/2025
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 425 W BANNOCK ST
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City | BOISE
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State | ID
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Zip | 83702-6035
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Country | US
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Telephone | 208-901-6094
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Fax | 208-343-5301
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Provider Business Mailing Address
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Address Line | 6382 S APEX AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-1060
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Country | US
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Telephone | 208-901-6094
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2671947
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License Number State | ID
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