=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871397562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVERY MARIE BURNETT N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 11/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 HOSPITAL WAY SUITE 204
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-5175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-239-2110
-----------------------------------------------------
Fax | 208-239-2119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 4168
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83205-4168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-238-1035
-----------------------------------------------------
Fax | 208-239-3626
-----------------------------------------------------
=====================================================
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 | 7871865
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 10997235-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------