Provider Demographics
NPI:1407410517
Name:BROWNELLER, NICHOLAS JOHN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
Last Name:BROWNELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 OAK ST
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-0359
Mailing Address - Country:US
Mailing Address - Phone:208-351-8968
Mailing Address - Fax:
Practice Address - Street 1:610 OAK ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855-0359
Practice Address - Country:US
Practice Address - Phone:208-351-8968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDA0003385Medicaid