Provider Demographics
NPI:1619035623
Name:MORNINGSTAR, ROSE (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MORNINGSTAR
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:WIEBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2151 W. HAYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-762-6772
Mailing Address - Fax:208-762-6773
Practice Address - Street 1:2151 W. HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-762-6772
Practice Address - Fax:208-762-6773
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA000011941225700000X
WAMA00011941225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist