Provider Demographics
NPI:1457897852
Name:WILLOUGHBY, SCOTT DONALD (FNP-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DONALD
Last Name:WILLOUGHBY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 N PENNGROVE WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7446
Mailing Address - Country:US
Mailing Address - Phone:208-938-3663
Mailing Address - Fax:208-938-3664
Practice Address - Street 1:4740 N. PENNGROVE WAY
Practice Address - Street 2:STE. 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-938-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID54825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily