# MOMMA LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376286732
- **Authorized official:** KELLIE NORTHAM PMHNP,BC (PRIMARY OPERATOR)
- **Authorized official phone:** (712) 828-0234

## Contact information

- **Practice address:** 116 18TH AVE S, NAMPA, ID 83651-4841
- **Practice address phone:** (208) 807-2867
- **Practice address fax:** (208) 639-2736
- **Mailing address:** 116 18TH AVE S, NAMPA, ID 83651-4841
- **Mailing address phone:** (208) 807-2867
- **Mailing address fax:** (208) 639-2736

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 04/14/2022
- **Last updated:** 04/14/2022