Provider Demographics
NPI:1508393976
Name:WIERSMA, KAILYN
Entity Type:Individual
Prefix:
First Name:KAILYN
Middle Name:
Last Name:WIERSMA
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 S CELEBRATION AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2779
Practice Address - Country:US
Practice Address - Phone:208-884-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501833208000000X
MI4301112092208000000X
IDM-16194208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics