Provider Demographics
NPI:1255090189
Name:KASALLIS, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KASALLIS
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 1:10717 W CATMINT DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-6205
Mailing Address - Country:US
Mailing Address - Phone:214-725-9142
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-7421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID29906163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care