Provider Demographics
NPI:1972684223
Name:PELLY, NICOLE W
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:W
Last Name:PELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-625-5085
Practice Address - Fax:208-625-5731
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13281207LH0002X
WAMD00041034207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Yes207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
294100OtherINTERNAL ID-MOTOR VEHICLE ID
G95228Medicare UPIN
8859057Medicare ID - Type Unspecified
WA8446197Medicaid