Provider Demographics
NPI:1831667468
Name:ROE, EDITH MARY (NP-BC)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:MARY
Last Name:ROE
Suffix:
Gender:F
Credentials:NP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W. IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEDALE
Mailing Address - State:ID
Mailing Address - Zip Code:83628
Mailing Address - Country:US
Mailing Address - Phone:208-337-7038
Mailing Address - Fax:208-337-4652
Practice Address - Street 1:126 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:HOMEDALE
Practice Address - State:ID
Practice Address - Zip Code:83628-0037
Practice Address - Country:US
Practice Address - Phone:208-337-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201910193NP363L00000X
ID60044363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner