Basic Information
| Provider Information | |||||||||
| NPI: | 1477088201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARDWELL | ||||||||
| FirstName: | KEELY | ||||||||
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| Credential: | DNAP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 781 N SHADOWRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165292518 | ||||||||
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| Practice Location | |||||||||
| Address1: | 338 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083360895 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2017 | ||||||||
| LastUpdateDate: | 10/04/2017 | ||||||||
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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 | 163W00000X | 40228 | ID | N | Nursing Service Providers | Registered Nurse | 163W00000X | 14-126679-032 | KS | N | Nursing Service Providers | Registered Nurse | 367500000X | 55952 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.