Provider Demographics
NPI:1861728933
Name:DUTCHER, ELLEN (FNP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:DUTCHER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4726 CENTER LN
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-3789
Mailing Address - Country:US
Mailing Address - Phone:208-741-1318
Mailing Address - Fax:
Practice Address - Street 1:4726 CENTER LN
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-3789
Practice Address - Country:US
Practice Address - Phone:208-741-1318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP395A364SF0001X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health