Individual
MRS. BEVERLEY ANN BLAKE ODOHERTY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CFNP
Contact information
Practice address
801 POLE LINE RD W, TWIN FALLS, ID 83301-5810
(208) 814-4100
(208) 814-4908
Mailing address
190 E BANNOCK ST, BOISE, ID 83712-6241
(208) 381-8752
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
RN172038
CO
363LF0000X
Family Nurse Practitioner
Primary
NP925A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
16301862
—
CO
Enumeration date
12/01/2006
Last updated
09/09/2024
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