Provider Demographics
NPI:1003546276
Name:WESTENDORF, MALINDA PAIGE
Entity Type:Individual
Prefix:MS
First Name:MALINDA
Middle Name:PAIGE
Last Name:WESTENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDY
Other - Middle Name:
Other - Last Name:WESTENDORF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8866
Mailing Address - Fax:
Practice Address - Street 1:465 MCKENNA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2143
Practice Address - Country:US
Practice Address - Phone:208-587-9703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
IDPA-2379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program