| NPI | 1104419423 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACY HUMPHERYS Practice Manager 208-252-5621 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| Enumeration Date | 2021-02-17 |
| Last Update Date | 2021-02-17 |