Provider Demographics
NPI:1316589278
Name:DEGEUS, MINDY LEE (NP-C)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:LEE
Last Name:DEGEUS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16564 SADIE AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-1476
Mailing Address - Country:US
Mailing Address - Phone:208-515-6072
Mailing Address - Fax:888-990-2969
Practice Address - Street 1:39 W PINE AVE STE B20
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2412
Practice Address - Country:US
Practice Address - Phone:208-286-8670
Practice Address - Fax:888-990-2969
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62731363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty