Provider Demographics
NPI:1083260194
Name:ELLIS, NATALIE (LMT, PTA)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E BLUE TICK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7474
Mailing Address - Country:US
Mailing Address - Phone:208-340-3318
Mailing Address - Fax:
Practice Address - Street 1:1625 W STATE ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4003
Practice Address - Country:US
Practice Address - Phone:208-336-0017
Practice Address - Fax:208-439-7657
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASA3541225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMASA3541OtherREGENCE