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Organization
LAKESIDE AESTHETICS - LLC
Active
Organization
LAKESIDE AESTHETICS - LLC
Active
Other names
Lakeside Medicine and Aesthetics LLC
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY FUHRMAN NP (OWNER/NP)
(208) 290-3302
Entity
Organization
Contact information
Practice address
1005 HIGHWAY 2, SANDPOINT, ID 83864-1702
(208) 290-3302
Mailing address
PO BOX 333, SAGLE, ID 83860-0333
(208) 290-3302
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
NULL
207Q00000X
Family Medicine Physician
—
—
363L00000X
Nurse Practitioner
—
NULL
363L00000X
Nurse Practitioner
—
—
363LF0000X
Family Nurse Practitioner
—
NULL
363LF0000X
Family Nurse Practitioner
—
—
363LP2300X
Primary Care Nurse Practitioner
Primary
NP1029A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NP1029A
IDAHO STATE LICENSE NUMBER
ID
Enumeration date
09/06/2018
Last updated
03/06/2019
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