=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033752498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SELAH WORLEY FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2019
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13500 PLEASANT VLY RD
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-336-0740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190174
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83719-0174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-880-5635
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 63076
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F10190631
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------