Provider Demographics
NPI:1205658978
Name:LEGAULT, SAMANTHA KAITLIN (FNP-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAITLIN
Last Name:LEGAULT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7848 W MCMULLEN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0839
Mailing Address - Country:US
Mailing Address - Phone:208-353-2928
Mailing Address - Fax:
Practice Address - Street 1:6933 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8616
Practice Address - Country:US
Practice Address - Phone:208-321-0634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8861276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily