MEDICARE: MRS. SHELBY L.R. STODDARD NP-C

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	24289A	ID

General Provider Information

NPI Number	:	1205198934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHELBY L.R. STODDARD NP-C

Provider Business Mailing Address
First Line	:	14114 ETHAN LN
Second Line	:
City	:	CHUBBUCK
State	:	ID
Zip	:	83202-5363
Country	:	US
Telephone Number	:	208-240-2363
Fax Number	:	208-646-3903

Provider Business Practice Location Address
First Line	:	435 S EAGLE RD STE 100
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-6018
Country	:	US
Telephone Number	:	208-609-9130
Fax Number	:	208-268-8781

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

Provider Enumeration Date	:	06/08/2012
Last Update Date	:	03/10/2026

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