Provider Demographics
NPI:1902124142
Name:THURMOND, ELIZABETH PUCKETT (RN MSN AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:PUCKETT
Last Name:THURMOND
Suffix:
Gender:F
Credentials:RN MSN AGACNP-BC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9850 ST LUKES DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7912
Mailing Address - Country:US
Mailing Address - Phone:208-505-2108
Mailing Address - Fax:
Practice Address - Street 1:9850 ST LUKES DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-7912
Practice Address - Country:US
Practice Address - Phone:208-505-2108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID56592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner