Provider Demographics
NPI:1114569282
Name:KENYEN, AMIE BETH (NP-C)
Entity Type:Individual
Prefix:MS
First Name:AMIE
Middle Name:BETH
Last Name:KENYEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3592 NATHAN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7948
Mailing Address - Country:US
Mailing Address - Phone:208-589-3844
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY STE 607
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2714
Practice Address - Country:US
Practice Address - Phone:208-589-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62679363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner