Provider Demographics
NPI:1326371766
Name:PACKER, NICOLE C (BS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:PACKER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5884 GLENEAGLES DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6336
Mailing Address - Country:US
Mailing Address - Phone:208-403-7221
Mailing Address - Fax:
Practice Address - Street 1:1740 E 17TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6375
Practice Address - Country:US
Practice Address - Phone:208-524-1278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-17
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator