Basic Information
| Provider Information | |||||||||
| NPI: | 1437350444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLSCLAW | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1075 N CURTIS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083230031 | ||||||||
| FaxNumber: | 2083230064 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 N CURTIS RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083230031 | ||||||||
| FaxNumber: | 2083230064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 163WC0200X | N-10853 | ID | Y | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | N-10853 | 01 | ID | REGISTERED NURSE | OTHER |