=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477181543
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRIANN BOANCA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2020
-----------------------------------------------------
Last Update Date | 10/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N ROBBINS RD STE 100
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83702-4539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-381-1615
-----------------------------------------------------
Fax | 208-381-5141
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 E BANNOCK ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83712-6241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 3271773
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | MD210011692
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | PG205706
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------