Provider Demographics
NPI:1952152415
Name:YOUNGBLOOD, EILEEN (RN)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 N FIRE OPAL AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2004
Mailing Address - Country:US
Mailing Address - Phone:718-877-1770
Mailing Address - Fax:
Practice Address - Street 1:250 W BOBWHITE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6643
Practice Address - Country:US
Practice Address - Phone:208-426-0052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID67667163WC0200X, 163WG0000X, 163WN1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice