Provider Demographics
NPI:1487061503
Name:BERMENSOLO, KAREN (RN, BSN)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BERMENSOLO
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:BERMENSOLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:5823 E PLAYWRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5500
Mailing Address - Country:US
Mailing Address - Phone:208-590-9981
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-47936163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse