=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487140265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATUSHKA OLGA MICHAEL MATERNITY ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 18TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-4841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-639-2700
-----------------------------------------------------
Fax | 208-639-2736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 13TH AVE S
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-4618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-828-0234
-----------------------------------------------------
Fax | 208-965-8789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KELLIE NORTHAM
-----------------------------------------------------
Credential | CNM
-----------------------------------------------------
Telephone | 712-828-0234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number | CNM81-A
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------