Provider Demographics
NPI:1467762856
Name:CONN, JENIFER SHANON (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:JENIFER
Middle Name:SHANON
Last Name:CONN
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-0600
Mailing Address - Fax:208-302-0755
Practice Address - Street 1:1510 12TH AVENUE RD STE 200
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-302-0600
Practice Address - Fax:208-302-0755
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN32302163WD0400X
ID60035363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN32302OtherN32302
ID60035OtherAPRN-CNP