Provider Demographics
NPI:1760872865
Name:BAILEY, NYKOL (CRNA)
Entity Type:Individual
Prefix:
First Name:NYKOL
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N SHIRTTAIL WAY
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3220
Mailing Address - Country:US
Mailing Address - Phone:435-459-4194
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:435-459-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-27
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID105690367500000X
ID70140363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered