Provider Demographics
NPI:1376286732
Name:MOMMA LLC
Entity Type:Organization
Organization Name:MOMMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP,BC
Authorized Official - Phone:712-828-0234
Mailing Address - Street 1:116 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4841
Mailing Address - Country:US
Mailing Address - Phone:208-807-2867
Mailing Address - Fax:208-639-2736
Practice Address - Street 1:116 18TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4841
Practice Address - Country:US
Practice Address - Phone:208-807-2867
Practice Address - Fax:208-639-2736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty