Provider Demographics
NPI:1275545568
Name:AMYX, CHERYL C
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:C
Last Name:AMYX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 N FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2715
Mailing Address - Country:US
Mailing Address - Phone:208-375-0500
Mailing Address - Fax:208-375-4310
Practice Address - Street 1:4750 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2715
Practice Address - Country:US
Practice Address - Phone:208-375-0500
Practice Address - Fax:208-375-4310
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-414A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806116100Medicaid
IDNPGD5OtherBLUE CROSS
ID0000100034952OtherBLUE SHIELD
IDS50993Medicare UPIN
ID1342765Medicare ID - Type Unspecified