Provider Demographics
NPI:1720687106
Name:RAICHART, SUNNY (FNP)
Entity Type:Individual
Prefix:MS
First Name:SUNNY
Middle Name:
Last Name:RAICHART
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 E 410 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5518
Mailing Address - Country:US
Mailing Address - Phone:208-589-4609
Mailing Address - Fax:
Practice Address - Street 1:2001 S WOODRUFF AVE STE 15B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6372
Practice Address - Country:US
Practice Address - Phone:208-357-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily