Provider Demographics
NPI:1619243631
Name:CROSS, KAREN L (FNP, MSN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:L
Last Name:CROSS
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 N BULLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8082
Mailing Address - Country:US
Mailing Address - Phone:208-297-5047
Mailing Address - Fax:
Practice Address - Street 1:2460 N BULLOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-8082
Practice Address - Country:US
Practice Address - Phone:208-392-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-23
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1198A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB03661Medicare UPIN