Provider Demographics
NPI:1811241748
Name:WAMBEKE, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WAMBEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 W SANETTA ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5047
Mailing Address - Country:US
Mailing Address - Phone:208-442-0429
Mailing Address - Fax:
Practice Address - Street 1:1031 W SANETTA ST
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5047
Practice Address - Country:US
Practice Address - Phone:208-442-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
IDLPC-5855251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker