Provider Demographics
NPI:1821693094
Name:RICKLEFS, MERJURIE FAIR (ARNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MERJURIE
Middle Name:FAIR
Last Name:RICKLEFS
Suffix:
Gender:F
Credentials:ARNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 S 25TH E STE 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4956
Mailing Address - Country:US
Mailing Address - Phone:208-821-0357
Mailing Address - Fax:
Practice Address - Street 1:3670 S 25TH E STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4956
Practice Address - Country:US
Practice Address - Phone:208-821-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66558363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health