Provider Demographics
NPI:1205489978
Name:KIPSUGE, KIMERENG KIPCHUMBA (NP)
Entity type:Individual
Prefix:
First Name:KIMERENG
Middle Name:KIPCHUMBA
Last Name:KIPSUGE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:KIMERENG
Other - Middle Name:KIPCHUMBA
Other - Last Name:KIPSUGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1883 WILDWOOD ST STE C
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5146
Mailing Address - Country:US
Mailing Address - Phone:208-901-7006
Mailing Address - Fax:949-561-4801
Practice Address - Street 1:1883 WILDWOOD ST STE C
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5146
Practice Address - Country:US
Practice Address - Phone:208-901-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62135363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care