Provider Demographics
NPI:1558564138
Name:SPEARS, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SPEARS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190601
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0601
Mailing Address - Country:US
Mailing Address - Phone:208-371-2703
Mailing Address - Fax:
Practice Address - Street 1:1902 JUDITH LN
Practice Address - Street 2:SUITE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5235
Practice Address - Country:US
Practice Address - Phone:208-658-0800
Practice Address - Fax:208-323-1894
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID17148A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health