Provider Demographics
NPI:1982336525
Name:KNICKREHM, PAIGE MARIE (NP, CNM, BSN)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:MARIE
Last Name:KNICKREHM
Suffix:
Gender:F
Credentials:NP, CNM, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD STE 3209
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6356
Practice Address - Country:US
Practice Address - Phone:208-706-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56047363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty