Provider Demographics
NPI:1376084673
Name:AHLQUIST, MARCI
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:
Last Name:AHLQUIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCI
Other - Middle Name:
Other - Last Name:DATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-CNP
Mailing Address - Street 1:775 POLE LINE ROAD WEST
Mailing Address - Street 2:SUITE NUMBER 203
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-814-8300
Mailing Address - Fax:208-733-8970
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:SUITE 203
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-8300
Practice Address - Fax:208-733-8970
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily