1487633293 NPI number — MRS. LYNDA J MARICLE-KUWAHARA APRN-C

Table of content: MRS. LYNDA J MARICLE-KUWAHARA APRN-C (NPI 1487633293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487633293 NPI number — MRS. LYNDA J MARICLE-KUWAHARA APRN-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARICLE-KUWAHARA
Provider First Name:
LYNDA
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARICLE
Provider Other First Name:
LYNDA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1487633293
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3852 HIGHWAY 21
Provider Second Line Business Mailing Address:
P.O. BOX 554
Provider Business Mailing Address City Name:
IDAHO CITY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83631-4176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-392-4544
Provider Business Mailing Address Fax Number:
208-392-4128

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3852 HIGHWAY 21
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO CITY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83631-4176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-392-4544
Provider Business Practice Location Address Fax Number:
208-392-4128
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  NP289 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP497 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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