Provider Demographics
NPI:1194229310
Name:LY, JEFFERY THOMAS (RN)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:THOMAS
Last Name:LY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11961 PHEASANT RUN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5082
Mailing Address - Country:US
Mailing Address - Phone:208-590-8166
Mailing Address - Fax:
Practice Address - Street 1:11961 PHEASANT RUN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5082
Practice Address - Country:US
Practice Address - Phone:208-590-8166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46147163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse