Provider Demographics
NPI:1699721837
Name:HUMPHREY, CARRIE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:ANN
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CARRIE
Other - Middle Name:ANN
Other - Last Name:GWILT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6200
Mailing Address - Fax:208-302-6255
Practice Address - Street 1:3217 W BAVARIA STREET
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-302-6200
Practice Address - Fax:208-302-6255
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9582208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics