Provider Demographics
NPI:1376510123
Name:DOMANGUE-SHIFLETT, NATALIE A (MD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:A
Last Name:DOMANGUE-SHIFLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:A
Other - Last Name:SHIFLETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4740 N PENNGROVE WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-938-3663
Mailing Address - Fax:208-938-3664
Practice Address - Street 1:4740 N PENNGROVE WAY
Practice Address - Street 2:STE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-938-3663
Practice Address - Fax:208-938-3664
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDH36269Medicaid
H36269Medicare UPIN