Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | NP-1307A | ID |
NPI | 1003248113 |
---|---|
Provider Name | Mrs. Nicole Marie Engledow |
First Address | Lewiston, ID 83501-2691 |
Second Address | Lewiston, ID 83501-2691 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2013 |
Last Update Date | 23/08/2013 |