Provider Demographics
NPI:1639950918
Name:MARSHALL, ETHEL ANNE (PMHNP)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:ANNE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:4614 SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-7405
Mailing Address - Country:US
Mailing Address - Phone:208-901-6691
Mailing Address - Fax:
Practice Address - Street 1:4614 N SAVANNAH LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-7405
Practice Address - Country:US
Practice Address - Phone:208-901-6691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID78682363LP0808X
IDCNP-78682363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health