Provider Demographics
NPI:1346437027
Name:STODDARD, WALLENE A (CNM)
Entity Type:Individual
Prefix:
First Name:WALLENE
Middle Name:A
Last Name:STODDARD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 N LINDER RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2437
Mailing Address - Country:US
Mailing Address - Phone:208-884-1223
Mailing Address - Fax:208-887-1935
Practice Address - Street 1:270 N LINDER RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-884-1223
Practice Address - Fax:208-887-1935
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57884163W00000X, 176B00000X
CA589572163WX0003X
CA1792367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID57884OtherIDAHO BOARD OF NURSING