Provider Demographics
NPI:1477589216
Name:BEAN, JUDI (NP)
Entity Type:Individual
Prefix:MS
First Name:JUDI
Middle Name:
Last Name:BEAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JULIANA
Other - Middle Name:
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1502 E REGATTA ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1139 E. WINDING CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-938-8887
Practice Address - Fax:208-938-8897
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP93A363LF0000X
WAAP30001704364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805183900Medicaid
ID805183900Medicaid