MEDICARE: MRS. LYNDA J MARICLE-KUWAHARA APRN-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	NP289	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NP497	OTHER	ID	BLUE CROSS

General Provider Information

NPI Number	:	1487633293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNDA J MARICLE-KUWAHARA APRN-C

Provider Business Mailing Address
First Line	:	3852 HIGHWAY 21
Second Line	:	P.O. BOX 554
City	:	IDAHO CITY
State	:	ID
Zip	:	83631-4176
Country	:	US
Telephone Number	:	208-392-4544
Fax Number	:	208-392-4128

Provider Business Practice Location Address
First Line	:	3852 HIGHWAY 21
Second Line	:
City	:	IDAHO CITY
State	:	ID
Zip	:	83631-4176
Country	:	US
Telephone Number	:	208-392-4544
Fax Number	:	208-392-4128

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

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	12/18/2007

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