Provider Demographics
NPI:1669162137
Name:ASHLINE, WILLIAM JACK (NNP)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JACK
Last Name:ASHLINE
Suffix:
Gender:M
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53654163WN0002X, 363LN0000X
ID104775275363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care