Provider Demographics
NPI:1184879363
Name:WICK, KATHRYN A (NP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:WICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ALICE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-467-3391
Practice Address - Street 1:300 S 23RD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-9100
Practice Address - Country:US
Practice Address - Phone:208-344-3512
Practice Address - Fax:208-344-4898
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-907A363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner