Provider Demographics
NPI:1053650010
Name:NORTHAM, KELLIE ANN (CNM, NP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:NORTHAM
Suffix:
Gender:F
Credentials:CNM, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4841
Mailing Address - Country:US
Mailing Address - Phone:208-639-2700
Mailing Address - Fax:208-639-2736
Practice Address - Street 1:116 18TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4841
Practice Address - Country:US
Practice Address - Phone:208-639-2700
Practice Address - Fax:208-639-2736
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM81-A367A00000X
ID61450363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA14FTPKJJAMedicaid