Provider Demographics
NPI:1255531976
Name:PRENGAMAN, MOLLY VAUGHAN (APN, FNP-BC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:VAUGHAN
Last Name:PRENGAMAN
Suffix:
Gender:F
Credentials:APN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 N COLE RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7361
Mailing Address - Country:US
Mailing Address - Phone:208-375-8806
Mailing Address - Fax:208-375-8826
Practice Address - Street 1:2308 N COLE RD
Practice Address - Street 2:SUITE H
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7361
Practice Address - Country:US
Practice Address - Phone:208-375-8806
Practice Address - Fax:208-375-8826
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP443A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8050180Medicaid