Provider Demographics
NPI:1710197264
Name:FAKENBRIDGE, KELLEEN LOUISE (NP)
Entity Type:Individual
Prefix:MS
First Name:KELLEEN
Middle Name:LOUISE
Last Name:FAKENBRIDGE
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 1:8324 W NORTHVIEW ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7184
Mailing Address - Country:US
Mailing Address - Phone:208-376-8337
Mailing Address - Fax:
Practice Address - Street 1:8324 W NORTHVIEW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7184
Practice Address - Country:US
Practice Address - Phone:208-376-8337
Practice Address - Fax:208-376-8344
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily