Provider Demographics
NPI:1710268099
Name:WHITEHEAD-PRICE, KELLY R (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:R
Last Name:WHITEHEAD-PRICE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3340 EAST GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6400
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 W. CHERRY LANE
Practice Address - Street 2:STE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8531
Practice Address - Country:US
Practice Address - Phone:208-302-6400
Practice Address - Fax:208-302-6455
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1067A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily