Provider Demographics
NPI:1285091306
Name:FUNKE, JULIE LEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:LEN
Last Name:FUNKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:LEN
Other - Last Name:FAIRLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-750-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1682A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health