# LAKESIDE AESTHETICS - LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lakeside Medicine and Aesthetics LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1851873756
- **Authorized official:** KELLY FUHRMAN NP (OWNER/NP)
- **Authorized official phone:** (208) 290-3302

## Contact information

- **Practice address:** 1005 HIGHWAY 2, SANDPOINT, ID 83864-1702
- **Practice address phone:** (208) 290-3302
- **Mailing address:** PO BOX 333, SAGLE, ID 83860-0333
- **Mailing address phone:** (208) 290-3302

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 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 | NP1029A | ID | Yes |

## Other

- **Enumeration date:** 09/06/2018
- **Last updated:** 03/06/2019

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | NP1029A | IDAHO STATE LICENSE NUMBER | ID |