Basic Information
| Provider Information | |||||||||
| NPI: | 1376084673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHLQUIST | ||||||||
| FirstName: | MARCI | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DATE | ||||||||
| OtherFirstName: | MARCI | ||||||||
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| OtherCredential: | APRN-CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 775 POLE LINE ROAD WEST | ||||||||
| Address2: | SUITE NUMBER 203 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148300 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088148300 | ||||||||
| FaxNumber: | 2087338970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 55418 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.