Basic Information
| Provider Information | |||||||||
| NPI: | 1104573112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STREET | ||||||||
| FirstName: | CASSIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | AGCANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 W BEESON ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837064716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767013823 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2022 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 66379 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.