Provider Demographics
NPI:1114309853
Name:MUSGROVE, JAMIE (NNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:MUSGROVE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W PLEASANTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-3837
Mailing Address - Country:US
Mailing Address - Phone:970-376-4017
Mailing Address - Fax:
Practice Address - Street 1:2402 W PLEASANTON AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-3837
Practice Address - Country:US
Practice Address - Phone:970-376-4017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0187605163WN0002X
IDNP-1615A363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care