Provider Demographics
NPI:1790544492
Name:SCHROEDER, KALIE ANN
Entity Type:Individual
Prefix:
First Name:KALIE
Middle Name:ANN
Last Name:SCHROEDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALIE
Other - Middle Name:ANN
Other - Last Name:GYDESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7466 W SAXTON DR # D308
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-5179
Mailing Address - Country:US
Mailing Address - Phone:208-940-0465
Mailing Address - Fax:
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-344-7799
Practice Address - Fax:208-947-1944
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant