Provider Demographics
NPI:1912352188
Name:BALSIMO, ANDREA MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:BALSIMO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:750 N SYRINGA ST STE 190
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:208-262-2328
Practice Address - Fax:208-619-5057
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70663363LF0000X, 363L00000X
MNR184567-5163W00000X
MNCNP 4651363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1912352188Medicaid