MEDICARE: KIRK EMIL PAOLINELLI JR. FNP

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	363L00000X	Nurse Practitioner	57230	ID
2	363LF0000X	Family Nurse Practitioner	95008301	CA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	57230	ID

General Provider Information

NPI Number	:	1235637240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRK EMIL PAOLINELLI JR. FNP

Provider Business Mailing Address
First Line	:	3340 E GOLDSTONE DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642
Country	:	US
Telephone Number	:	208-302-5950
Fax Number	:	208-302-5955

Provider Business Practice Location Address
First Line	:	4783 N SUMMIT WAY
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5017
Country	:	US
Telephone Number	:	208-515-2273
Fax Number	:

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

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	12/13/2024

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