Provider Demographics
NPI:1467855403
Name:EMMETT, CLINT (APRN)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:EMMETT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E E ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2713
Mailing Address - Country:US
Mailing Address - Phone:603-915-6135
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR # MS 3140
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-2006
Practice Address - Country:US
Practice Address - Phone:208-885-6716
Practice Address - Fax:208-885-4354
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH07060823363LP0808X
ID61523363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH07060823OtherNH APRN LICENSE
ID61523OtherID APRN LICENSE