Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | NP-1615A | ID |
NPI | 1114309853 |
---|---|
Provider Name | Jamie Musgrove |
First Address | Boise, ID 83702-3837 |
Second Address | Boise, ID 83702-3837 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/06/2015 |
Last Update Date | 20/08/2015 |