MEDICARE: MS. BETH ELAINE LANDIS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	N-34045	ID

General Provider Information

NPI Number	:	1013915164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETH ELAINE LANDIS NP

Provider Business Mailing Address
First Line	:	1540 E RIVERS END CT
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-6390
Country	:	US
Telephone Number	:	208-939-6030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1540 E RIVERS END CT
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-6390
Country	:	US
Telephone Number	:	208-939-6030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/02/2010

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