Provider Demographics
NPI:1750920401
Name:FUNCTIONAL MEDICINE OF NORTH IDAHO, PLLC
Entity type:Organization
Organization Name:FUNCTIONAL MEDICINE OF NORTH IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAPLANTE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:208-635-5265
Mailing Address - Street 1:1399 N BIZTOWN LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5044
Mailing Address - Country:US
Mailing Address - Phone:208-635-5265
Mailing Address - Fax:208-635-5218
Practice Address - Street 1:8382 N WAYNE DR STE 204
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6028
Practice Address - Country:US
Practice Address - Phone:208-635-5265
Practice Address - Fax:208-635-5218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-29
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center