Individual
JENNY RICKELL WILLMORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.-C.
Contact information
Practice address
605 MAPLE AVE, SAINT ANTHONY, ID 83445-5529
(208) 624-4002
(208) 624-4409
Mailing address
605 MAPLE AVE, SAINT ANTHONY, ID 83445-5529
(208) 624-4402
(208) 624-4409
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-519
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807122700
—
ID
Enumeration date
10/31/2006
Last updated
09/25/2012
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