Provider Demographics
NPI:1790106813
Name:PAGET, ELLEN CONNOLLY (ARNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CONNOLLY
Last Name:PAGET
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:CONNOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83701-0640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2347 E GALA ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4881
Practice Address - Country:US
Practice Address - Phone:208-323-3767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-16
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60396775363L00000X, 363LF0000X
ID67910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1790106813Medicaid
WA8926361Medicare PIN
WA8926363Medicare PIN
WA8926362Medicare PIN