Provider Demographics
NPI:1952186876
Name:WEDDINGTON, IMELDA JOAN (NP)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:JOAN
Last Name:WEDDINGTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 S ISLAND GLENN WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13500 S PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2709
Practice Address - Country:US
Practice Address - Phone:208-658-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID77183363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health