Provider Demographics
NPI:1053650010
Name:NORTHAM, KELLIE ANN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:NORTHAM
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4618
Mailing Address - Country:US
Mailing Address - Phone:712-828-0234
Mailing Address - Fax:208-965-8789
Practice Address - Street 1:192 WEST STATE STREET
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-807-2867
Practice Address - Fax:208-639-2736
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-11
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM81-A367A00000X
IDCNP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14FTPKJJAMedicaid