Provider Demographics
NPI:1396292421
Name:KHANDAKER, LYNNETTE MICHELLE (APRN-NP)
Entity type:Individual
Prefix:MRS
First Name:LYNNETTE
Middle Name:MICHELLE
Last Name:KHANDAKER
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10112 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1428
Mailing Address - Country:US
Mailing Address - Phone:208-780-3900
Mailing Address - Fax:208-375-2882
Practice Address - Street 1:10112 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1428
Practice Address - Country:US
Practice Address - Phone:087-803-9002
Practice Address - Fax:208-375-2882
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN201537163WG0000X
IDNP60046363L00000X
ID60046363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1477920270Medicaid