Organization
MOMMA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KELLIE NORTHAM PMHNP,BC (PRIMARY OPERATOR)
(712) 828-0234
Entity
Organization
Contact information
Practice address
116 18TH AVE S, NAMPA, ID 83651-4841
(208) 807-2867
(208) 639-2736
Mailing address
116 18TH AVE S, NAMPA, ID 83651-4841
(208) 807-2867
(208) 639-2736
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Enumeration date
04/14/2022
Last updated
04/14/2022
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