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General NPI Number Information
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NPI Number | 1326877762
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Entity Type | Organization
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Legal Business Name | ADDI
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Dates
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Enumeration Date | 08/01/2024
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Last Update Date | 10/14/2024
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Provider Practice Location Address
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Address Line | 1526 W USTICK RD STE 110
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City | MERIDIAN
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State | ID
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Zip | 83646-7741
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Country | US
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Telephone | 208-370-5888
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Fax |
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Provider Business Mailing Address
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Address Line | 1672 S WOODSAGE AVE
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City | MERIDIAN
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State | ID
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Zip | 83642-8329
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Country | US
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Telephone | 208-515-2273
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Fax |
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Authorized Official
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Title or Position | CEO/MEDICAL DIRECTOR
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Name | KYLE RONNAU
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Credential | NP, PMHNP
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Telephone | 208-515-2273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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