Basic Information
Provider Information | |||||||||
NPI: | 1548521396 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHINNEY | ||||||||
FirstName: | NANETTE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 444 HOSPITAL WAY | ||||||||
Address2: | SUITE 801 | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832012745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082326214 | ||||||||
FaxNumber: | 2082333416 | ||||||||
Practice Location | |||||||||
Address1: | 444 HOSPITAL WAY | ||||||||
Address2: | SUITE 801 | ||||||||
City: | POCATELLO | ||||||||
State: | ID | ||||||||
PostalCode: | 832012745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082326214 | ||||||||
FaxNumber: | 2082333416 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2012 | ||||||||
LastUpdateDate: | 06/07/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N-21500 | ID | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.