Provider Demographics
NPI:1144950353
Name:BACCA, AMY L (APRN AGCNS-BC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:BACCA
Suffix:
Gender:F
Credentials:APRN AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 N STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-3356
Mailing Address - Country:US
Mailing Address - Phone:208-447-7138
Mailing Address - Fax:
Practice Address - Street 1:720 E PARK BLVD STE 260
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-7765
Practice Address - Country:US
Practice Address - Phone:208-381-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID67616364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist