MEDICARE: ANA LINDA LABORDE AGNP-BC

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	363LA2200X	Adult Health Nurse Practitioner	730989	TX
2	363LG0600X	Gerontology Nurse Practitioner	730989	TX
3	363LG0600X	Gerontology Nurse Practitioner	59811	ID
4	363LA2200X	Adult Health Nurse Practitioner	59811	ID

General Provider Information

NPI Number	:	1952883571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANA LINDA LABORDE AGNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 1278
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-1278
Country	:	US
Telephone Number	:	89-945-5752
Fax Number	:	208-994-5576

Provider Business Practice Location Address
First Line	:	219 S WOODDALE AVE
Second Line	:
City	:	EAGLE
State	:	ID
Zip	:	83616-7714
Country	:	US
Telephone Number	:	208-994-5575
Fax Number	:	208-994-5576

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

Provider Enumeration Date	:	08/30/2018
Last Update Date	:	10/04/2022

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