Provider Demographics
NPI:1003689449
Name:KNIGHT, TANEESHA MISHEL
Entity Type:Individual
Prefix:
First Name:TANEESHA
Middle Name:MISHEL
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 S FITNESS PL STE 150
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-7035
Mailing Address - Country:US
Mailing Address - Phone:805-750-0323
Mailing Address - Fax:
Practice Address - Street 1:539 S FITNESS PL STE 150
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7035
Practice Address - Country:US
Practice Address - Phone:805-750-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty