Provider Demographics
NPI:1386987055
Name:QUAYLE, KATHERINE WINGATE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:WINGATE
Last Name:QUAYLE
Suffix:
Gender:F
Credentials:
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 1:1450 AVIATION DR STE 202
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8785
Practice Address - Country:US
Practice Address - Phone:208-727-8970
Practice Address - Fax:208-727-8979
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.2521412084P0800X
IDM-142632084P0800X
UT9148249-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics