Provider Demographics
NPI:1245229558
Name:TRABERT, ALICE R (FNP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:R
Last Name:TRABERT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:132 5TH AVE W
Practice Address - Street 2:SUITE 1
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-1825
Practice Address - Country:US
Practice Address - Phone:208-814-9800
Practice Address - Fax:208-814-9833
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-484A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1245229558Medicare PIN
ID20004654Medicare PIN