Provider Demographics
NPI:1477323947
Name:MACE, KATRINA LARENE
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LARENE
Last Name:MACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MAPLEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5511
Mailing Address - Country:US
Mailing Address - Phone:208-431-4898
Mailing Address - Fax:
Practice Address - Street 1:999 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-9001
Practice Address - Country:US
Practice Address - Phone:208-297-3428
Practice Address - Fax:208-297-3978
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78422363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty