Provider Demographics
NPI:1235973363
Name:GICHURU, SALOME WAITHERERO
Entity type:Individual
Prefix:
First Name:SALOME
Middle Name:WAITHERERO
Last Name:GICHURU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALOME
Other - Middle Name:WAITHERERO
Other - Last Name:HAYBALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HAYBALL
Mailing Address - Street 1:5391 S POLARIS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDAIN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-760-7635
Mailing Address - Fax:
Practice Address - Street 1:5391 S POLARIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8554
Practice Address - Country:US
Practice Address - Phone:208-760-7635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID79818163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health