Provider Demographics
NPI:1659405686
Name:GEORGE, GAIL R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:GAIL
Middle Name:R
Last Name:GEORGE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2956 TRAIL CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276-5216
Mailing Address - Country:US
Mailing Address - Phone:208-547-2369
Mailing Address - Fax:
Practice Address - Street 1:1451 FORE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4300
Practice Address - Country:US
Practice Address - Phone:208-236-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID268A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily