=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982422564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCNALLY MOBILE CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5089 SE 1 1/2 AVE
-----------------------------------------------------
City | NEW PLYMOUTH
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83655-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 986-207-1720
-----------------------------------------------------
Fax | 866-531-4582
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5089 SE 1 1/2 AVE
-----------------------------------------------------
City | NEW PLYMOUTH
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83655-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 986-200-6219
-----------------------------------------------------
Fax | 866-531-4582
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CRYSTAL MCNALLY
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 986-200-6219
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------